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Jeffrey D Coe,1 James F Zucherman,2 Donald W Kucharzyk,3 Kornelis A Poelstra,4 Larry E Miller,5 Sandeep Kunwar,6 1Silicon Valley Spine Institute, Campbell, 2San Francisco Orthopaedic Surgeons, San Francisco, CA, 3Orthopaedic Pediatric and Spine, Crown Point, IN, 4Department of Surgery, Sacred Heart Hospital on the Emerald Coast, Miramar Beach, FL, 5Miller Scientific Consulting, Inc., Asheville, NC, 6Bell Neuroscience Institute, Washington Hospital Healthcare System, Fremont, CA, USA Abstract: The increasing adoption of minimally invasive techniques for spine surgery in recent years has led to significant advancements in instrumentation for lumbar interbody fusion. Percutaneous pedicle screw fixation is now a mature technology, but the role of expandable cages is still evolving. The capability to deliver a multiexpandable interbody cage with a large footprint through a narrow surgical cannula represents a significant advancement in spinal surgery technology. The purpose of this report is to describe a multiexpandable lumbar interbody fusion cage, including implant characteristics, intended use, surgical technique, preclinical testing, and early clinical experience. Results to date suggest that the multiexpandable cage allows a less invasive approach to posterior/transforaminal lumbar interbody fusion surgery by minimizing iatrogenic risks associated with static or vertically expanding interbody prostheses while providing immediate vertebral height restoration, restoration of anatomic alignment, and excellent early-term clinical results. Keywords: degenerative disc disease, expandable, low back pain, Luna

STUDY DESIGN: Retrospective review of a prospectively collected, multicentered database from the Scoliosis Research Society. OBJECTIVES: To evaluate incidences of complications in a series of spinal fusions for Scheuermann kyphosis (SK) and to assess whether the incidence of complications is associated with patient age and surgical approach. SUMMARY OF BACKGROUND DATA: Although there is some evidence that adolescents have lower complication rates for spinal deformity surgery, this has not been well-documented for SK. Moreover, there is a lack of consensus on surgical approach for the management of SK. METHODS: The Scoliosis Research Society morbidity and mortality database was queried to identify cases of SK from 2001 to 2004. Complications rates were analyzed based on patient age and surgical approach. Pediatric and adult patients were defined as 19 year old, respectively. RESULTS: A total of 683 procedures involving spinal fusion for SK were identified. Mean patient age was 21 years (range: 5-75 years), with the majority (73%) of patients

Polyethylene (C 2 H 4 ) n was compressed to pressures between 10 and 30 GPa in a diamond anvil cell (DAC) and laser heated above 2500 K for approximately one second. This resulted in the chemical decomposition of the polymer into carbon and hydrocarbon reaction products. After quenching to ambient temperature, the decomposition products were measured in the DAC at pressures ranging from ambient to 29 GPa using a combination of x-ray diffraction (XRD) and small angle x-ray scattering (SAXS). XRD identified cubic diamond and methane as the predominant product species with their pressure-volume relationships exhibiting strong correlations to the diamond and methane equations of state. Length scales associated with the diamond products, obtained from SAXS measurements, indicate the formation of nanodiamonds with a radius of gyration between 12 and 35 nm consistent with 32-90 nm diameter spherical particles. These results are in good agreement with the predicted product composition under thermodynamic and chemical equilibrium., (© 2022. The Author(s).)

Benzene (C 6 H 6 ), while stable under ambient conditions, can become chemically reactive at high pressures and temperatures, such as under shock loading conditions. Here, we report in situ x-ray diffraction and small angle x-ray scattering measurements of liquid benzene shocked to 55 GPa, capturing the morphology and crystalline structure of the shock-driven reaction products at nanosecond timescales. The shock-driven chemical reactions in benzene observed using coherent XFEL x-rays were a complex mixture of products composed of carbon and hydrocarbon allotropes. In contrast to the conventional description of diamond, methane and hydrogen formation, our present results indicate that benzene's shock-driven reaction products consist of layered sheet-like hydrocarbon structures and nanosized carbon clusters with mixed sp 2 -sp 3 hybridized bonding. Implications of these findings range from guiding shock synthesis of novel compounds to the fundamentals of carbon transport in planetary physics., (© 2021. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Serial femtosecond crystallography (SFX) with X-ray free electron lasers (XFELs) allows structure determination of membrane proteins and time-resolved crystallography. Common liquid sample delivery continuously jets the protein crystal suspension into the path of the XFEL, wasting a vast amount of sample due to the pulsed nature of all current XFEL sources. The European XFEL (EuXFEL) delivers femtosecond (fs) X-ray pulses in trains spaced 100 ms apart whereas pulses within trains are currently separated by 889 ns. Therefore, continuous sample delivery via fast jets wastes >99% of sample. Here, we introduce a microfluidic device delivering crystal laden droplets segmented with an immiscible oil reducing sample waste and demonstrate droplet injection at the EuXFEL compatible with high pressure liquid delivery of an SFX experiment. While achieving ~60% reduction in sample waste, we determine the structure of the enzyme 3-deoxy-D-manno-octulosonate-8-phosphate synthase from microcrystals delivered in droplets revealing distinct structural features not previously reported.

Polymers and foams are pervasive in everyday life, as well as in specialized contexts such as space exploration, industry, and defense. They are frequently subject to shock loading in the latter cases, and will chemically decompose to small molecule gases and carbon (soot) under loads of sufficient strength. We review a body of work-most of it performed at Los Alamos National Laboratory-on polymers and foams under extreme conditions. To provide some context, we begin with a brief review of basic concepts in shockwave physics, including features particular to transitions (chemical reaction or phase transition) entailing an abrupt reduction in volume. We then discuss chemical formulations and synthesis, as well as experimental platforms used to interrogate polymers under shock loading. A high-level summary of equations of state for polymers and their decomposition products is provided, and their application illustrated. We then present results including temperatures and product compositions, thresholds for reaction, wave profiles, and some peculiarities of traditional modeling approaches. We close with some thoughts regarding future work.

Cytochrome c oxidase (C c O) reduces dioxygen to water and harnesses the chemical energy to drive proton translocation across the inner mitochondrial membrane by an unresolved mechanism. By using time-resolved serial femtosecond crystallography, we identified a key oxygen intermediate of bovine C c O. It is assigned to the P R -intermediate, which is characterized by specific redox states of the metal centers and a distinct protein conformation. The heme a 3 iron atom is in a ferryl (Fe 4+ = O 2- ) configuration, and heme a and Cu B are oxidized while Cu A is reduced. A Helix-X segment is poised in an open conformational state; the heme a farnesyl sidechain is H-bonded to S382, and loop-I-II adopts a distinct structure. These data offer insights into the mechanism by which the oxygen chemistry is coupled to unidirectional proton translocation., Competing Interests: The authors declare no conflict of interest.

We performed a series of plate impact experiments on NH 3 gas initially at room temperature and at a pressure of ∼100 psi. Shocked states were determined by optical velocimetry and the temperatures by optical pyrometry, yielding compression ratios of ∼5-10 and second shock temperatures in excess of 7500 K. A first-principles statistical mechanical (thermochemical) approach that included chemical dissociation yielded reasonable agreement with experimental results on the principal Hugoniot, even with interparticle interactions neglected. Theoretical analysis of reshocked states, which predicts a significant degree of chemical dissociation, showed reasonable agreement with experimental data for higher temperature shots; however, reshock calculations required the use of interaction potentials. We rationalize the very different shock temperatures obtained, relative to previous results for argon, in terms of atomic versus molecular heat capacities.

Dust elemental levels can be expressed as concentrations (bulk samples) or surface loadings (wipe samples). Wipe sampling has not been widely adopted for elements other than lead (Pb). In this study, 433 wipe samples from 130 households in south west England - a region of widespread, natural and anthropogenic arsenic contamination linked with previous mining activities-were analysed to (i) quantify loadings of arsenic (As); (ii) assess the quality of wipe data using QA/QC criteria; (iii) estimate, using published ingestion rates, human exposure to As in dust using loadings and concentrations from 97 bulk samples and (iv) comparatively assess the performance of wipe and bulk sampling using associations with As biomonitoring data (urine, toenails and hair). Good QC performance was observed for wipes: strong agreement between field duplicates, non-detectable contamination of field blank wipes and good reference material recoveries. Arsenic loadings exceeded an existing urban background benchmark in 67 (52%) households. No exceedances of tolerable daily As intake were observed for adult exposure estimates but infant estimates exceeded for 1 household. Infant estimates calculated using bulk concentrations resulted in 4 (3%) exceedances. Neither wipe nor bulk As metrics were sufficiently better predictors of As in biospecimens. Sampling strategies, analytical protocols, exposure metrics and assessment criteria require refinement to validate dust sampling methodologies.

Background: The KAST (Kiva Safety and Efficacy) investigation device exempt (IDE) study indicated that the majority of patients responded equally well to vertebral augmentation using either an implant-based approach or balloon kyphoplasty (BK). Additional investigation has suggested that a subset of patients may benefit further by avoiding repeated readmissions due to serious adverse events (SAEs) if they receive one vertebral augmentation approach over another., Objectives: The primary aim was to assess the effect of 2 different augmentation procedures on readmission rates for SAEs., Study Design: The KAST trial is a pivotal, multicenter, randomized, controlled trial conducted to evaluate an implant-based vertebral augmentation approach (implant) against BK. Post-hoc analysis was performed to evaluate SAEs and readmission rates., Setting: Twenty-one sites in North America and Europe., Methods: The treatment effect of vertebral implant versus BK on SAEs requiring unplanned readmission was evaluated by estimating the risk of SAEs associated with readmissions in KAST while controlling for key baseline covariates using multivariate Poisson regression modeling., Results: Forty (27.8%) patients with implants had 69 SAEs associated with readmission compared to 44 (31.2%) patients with BK having 103 events. The risk for all SAEs leading to readmission was 34.4% lower with the implant than for BK (95% confidence interval = 11.1%, 51.7%; P < 0.01). Multivariate analysis showed that the risk of SAEs associated with readmission was decreased in subjects treated with the implant compared to BK, and increased in patients with prior histories of vertebral compression fractures (VCFs) or significant osteoporosis., Limitations: The power of the KIVA study was based on clinical efficacy criteria to meet FDA requirements and recommendations for equivalency or noninferiority. The primary endpoint in this post-hoc analysis is SAEs associated with readmissions; as a result, the sample size is underpowered, although the results remain significant., Conclusion: The augmentation approaches compared here have similar pain relief and quality of life effects; the implant showed a lower risk of readmissions., Trial Registration: ClinicalTrials.gov Identifier: NCT01123512. Key words: Vertebral compression fracture, kiva implant, balloon kyphoplasty, vertebroplasty, health economics, osteoporosis.

Cytochrome c oxidase (C c O), the terminal enzyme in the electron transfer chain, translocates protons across the inner mitochondrial membrane by harnessing the free energy generated by the reduction of oxygen to water. Several redox-coupled proton translocation mechanisms have been proposed, but they lack confirmation, in part from the absence of reliable structural information due to radiation damage artifacts caused by the intense synchrotron radiation. Here we report the room temperature, neutral pH (6.8), damage-free structure of bovine C c O (bC c O) in the carbon monoxide (CO)-bound state at a resolution of 2.3 Å, obtained by serial femtosecond X-ray crystallography (SFX) with an X-ray free electron laser. As a comparison, an equivalent structure was obtained at a resolution of 1.95 Å, from data collected at a synchrotron light source. In the SFX structure, the CO is coordinated to the heme a 3 iron atom, with a bent Fe-C-O angle of ∼142°. In contrast, in the synchrotron structure, the Fe-CO bond is cleaved; CO relocates to a new site near Cu B , which, in turn, moves closer to the heme a 3 iron by ∼0.38 Å. Structural comparison reveals that ligand binding to the heme a 3 iron in the SFX structure is associated with an allosteric structural transition, involving partial unwinding of the helix-X between heme a and a 3 , thereby establishing a communication linkage between the two heme groups, setting the stage for proton translocation during the ensuing redox chemistry., Competing Interests: The authors declare no conflict of interest.

Riboswitches are structural RNA elements that are generally located in the 5' untranslated region of messenger RNA. During regulation of gene expression, ligand binding to the aptamer domain of a riboswitch triggers a signal to the downstream expression platform. A complete understanding of the structural basis of this mechanism requires the ability to study structural changes over time. Here we use femtosecond X-ray free electron laser (XFEL) pulses to obtain structural measurements from crystals so small that diffusion of a ligand can be timed to initiate a reaction before diffraction. We demonstrate this approach by determining four structures of the adenine riboswitch aptamer domain during the course of a reaction, involving two unbound apo structures, one ligand-bound intermediate, and the final ligand-bound conformation. These structures support a reaction mechanism model with at least four states and illustrate the structural basis of signal transmission. The three-way junction and the P1 switch helix of the two apo conformers are notably different from those in the ligand-bound conformation. Our time-resolved crystallographic measurements with a 10-second delay captured the structure of an intermediate with changes in the binding pocket that accommodate the ligand. With at least a 10-minute delay, the RNA molecules were fully converted to the ligand-bound state, in which the substantial conformational changes resulted in conversion of the space group. Such notable changes in crystallo highlight the important opportunities that micro- and nanocrystals may offer in these and similar time-resolved diffraction studies. Together, these results demonstrate the potential of 'mix-and-inject' time-resolved serial crystallography to study biochemically important interactions between biomacromolecules and ligands, including those that involve large conformational changes.

Spinal deformity in the adult is a common medical disorder with a significant and measurable impact on health-related quality of life. The ability to measure and quantify patient self-reported health status with disease-specific and general health status measures, and to correlate health status with radiographic and clinical measures of spinal deformity, has enabled significant advances in the assessment of the impact of deformity on our population, and in the evaluation and management of spinal deformity using an evidence-based approach. There has been a significant paradigm shift in the evaluation and management of patients with adult deformity. The paradigm shift includes development of validated, disease-specific measures of health status, recognition of deformity in the sagittal plane as a primary determinant of health status, and information on results of operative and medical/interventional management strategies for adults with spinal deformity. Since its inception in 1966, the Scoliosis Research Society (SRS) has been an international catalyst for improving the research and care for patients of all ages with spinal deformity. The SRS Adult Spinal Deformity Committee serves the mission of developing and defining an evidence-based approach to the evaluation and management of adult spinal deformity. The purpose of this overview from the SRS Adult Deformity Committee is to provide current information on the epidemiology and impact of adult deformity, and to provide patients, physicians, and policy makers a guide to the evidence-based evaluation and management of patients with adult deformity., (Copyright © 2016 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Second harmonic generation correlation spectroscopy (SHG-CS) is demonstrated as a new approach to protein nanocrystal characterization. A novel line-scanning approach was performed to enable autocorrelation analysis without sample damage from the intense incident beam. An analytical model for autocorrelation was developed, which includes a correction for the optical scattering forces arising when focusing intense, infrared beams. SHG-CS was applied to the analysis of BaTiO3 nanoparticles ranging from 200 to ∼500 nm and of photosystem I nanocrystals. A size distribution was recovered for each sample and compared with the size histogram measured by scanning electron microscopy (SEM). Good agreement was observed between the two independent measurements. The intrinsic selectivity of the second-order nonlinear optical process provides SHG-CS with the ability to distinguish well ordered nanocrystals from conglomerates and amorphous aggregates. Combining the recovered distribution of particle diameters with the histogram of measured SHG intensities provides the inherent hyperpolarizability per unit volume of the SHG-active nanoparticles. Simulations suggest that the SHG activity per unit volume is likely to exhibit relatively low sensitivity to the subtle distortions within the lattice that contribute to resolution loss in X-ray diffraction, but high sensitivity to the presence of multi-domain crystals.

We present the first application of reactive Monte Carlo in a first-principles context. The algorithm samples in a modified NVT ensemble in which the volume, temperature, and total number of atoms of a given type are held fixed, but molecular composition is allowed to evolve through stochastic variation of chemical connectivity. We discuss general features of the method, as well as techniques needed to enhance the efficiency of Boltzmann sampling. Finally, we compare the results of simulation of NH3 to those of ab initio molecular dynamics (AIMD). We find that there are regions of state space for which RxMC sampling is much more efficient than AIMD due to the "rare-event" character of chemical reactions.

A variety of organisms have evolved mechanisms to detect and respond to light, in which the response is mediated by protein structural changes after photon absorption. The initial step is often the photoisomerization of a conjugated chromophore. Isomerization occurs on ultrafast time scales and is substantially influenced by the chromophore environment. Here we identify structural changes associated with the earliest steps in the trans-to-cis isomerization of the chromophore in photoactive yellow protein. Femtosecond hard x-ray pulses emitted by the Linac Coherent Light Source were used to conduct time-resolved serial femtosecond crystallography on photoactive yellow protein microcrystals over a time range from 100 femtoseconds to 3 picoseconds to determine the structural dynamics of the photoisomerization reaction., (Copyright © 2016, American Association for the Advancement of Science.)

The extended Lagrangian Born-Oppenheimer molecular dynamics formalism [Niklasson, Phys. Rev. Lett., 2008, 100, 123004] has been applied to a tight-binding model under the constraint of local charge neutrality to yield microcanonical trajectories with both precise, long-term energy conservation and a reduced number of self-consistent field optimizations at each time step. The extended Lagrangian molecular dynamics formalism restores time reversal symmetry in the propagation of the electronic degrees of freedom, and it enables the efficient and accurate self-consistent optimization of the chemical potential and atomwise potential energy shifts in the on-site elements of the tight-binding Hamiltonian that are required when enforcing local charge neutrality. These capabilities are illustrated with microcanonical molecular dynamics simulations of a small metallic cluster using an sd-valent tight-binding model for titanium. The effects of weak dissipation on the propagation of the auxiliary degrees of freedom for the chemical potential and on-site Hamiltonian matrix elements that is used to counteract the accumulation of numerical noise during trajectories was also investigated.

Study Design: An electronic survey administered to Scoliosis Research Society membership., Objective: To characterize surgeon views regarding proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) management providing the framework in which a PJK/PJF classification system and treatment guidelines could be established., Summary of Background Data: PJK/PJF are common complications of adult spinal deformity surgery. To date, there is no consensus on PJK/PJF definitions, classification, and indications for revision surgery. There is a paucity of data on deformity surgeon practice pattern variations and consensus opinion on treatment and prevention., Methods: An electronic 19-question survey regarding PJK/PJF was administered to members of the Scoliosis Research Society who treat adult spinal deformity. Determinants included the surgeons' type of practice, number of years in practice, agreement with given PJK/PJF definitions, importance of key factors influencing prevention and revision, prevention methods currently used, and the importance of developing a classification system., Results: A total of 226 surgeons responded (38.8% response rate). Both 44.4% of surgeons selected "extremely important" and 40.8% selected "very important" that PJK in adult spinal deformity surgery is a very important issue and that a Scoliosis Research Society PJK/PJF classification system and guidelines for detection and prevention of PJK/PJF is a "must have" (18.1%) and "very likely helpful" (31.9%). Both 86.2% and 90.7% of surgeons agreed with the provided definitions of PJK and PJF, respectively. Top 5 revision indications included neurological deficit, severe focal pain, translation or subluxation fracture, a change in kyphosis angle of greater than 30°, chance fracture, spondylolisthesis greater than 6 mm, and instrumentation prominence. The majority of respondents use a PJK/PJF prevention strategy 60% of the time or more, the most common were terminal rod contour, preoperative bone mineral density testing, and frequent radiographical studies during first 3 months postoperative, preoperative bone mineral density medication for low bone mineral density., Conclusion: The results of this study provide insight from the practicing surgeons' perspective of the management of PJK and PJF that may aid in the validation of current definitions and consensus-based treatment decisions and prevention guidelines., Level of Evidence: 5.

Study Design: Systematic review of literature., Objective: To perform a comprehensive English language systematic literature review of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF), concentrating on incidence, risk factors, health related quality of life impact, prevention strategy, and classification systems., Summary of Background Data: PJK and PJF are well described clinical pathologies and are a frequent cause of revision surgery. The development of a PJK classification that correlates with clinical outcomes and guides treatment decisions and possible prevention strategies would be of significant benefit to patients and surgeons., Methods: The phrases "proximal junctional," "proximal junctional kyphosis," and "proximal junctional failure" were used as search terms in PubMed for all years up to 2014 to identify all articles that included at least one of these terms., Results: Fifty-three articles were identified overall. Eighteen articles assessed for risk factors. Eight studies specifically reviewed prevention strategies. There were no randomized prospective studies. There were 3 published studies that have attempted to classify PJK. The reported incidence of PJK ranged widely, from 5% to 46% in patients undergoing spinal instrumentation and fusion for adult spinal deformity. It is reported that 66% of PJK occurs within 3 months and 80% within 18 months after surgery. The reported revision rates due to PJK range from 13% to 55%. Modifiable and nonmodifiable risk factors for PJK have been characterized., Conclusion: PJK and PJF affect many patients after long segment instrumentation after the correction of adult spinal deformity. The epidemiology and risk factors for the disease are well defined. A PJK and PJF scoring system may help describe the severity of disease and guide the need for revision surgery. The development and prospective validation of a PJK classification system is important considering the prevalence of the problem and its clinical and economic impact., Level of Evidence: N/A.

The room temperature stability of 3,3'-diamino-4,4'-azoxyfurazan (DAAF) has been investigated using synchrotron far-infrared, mid-infrared, Raman spectroscopy, and synchrotron X-ray diffraction (XRD) up to 20 GPa. The as-loaded DAAF samples exhibited subtle pressure-induced ordering phenomena (associated with positional disorder of the azoxy "O" atom) resulting in doubling of the a-axis, to form a superlattice similar to the low-temperature polymorph. Neither high pressure synchrotron XRD, nor high pressure infrared or Raman spectroscopies indicated the presence of structural phase transitions up to 20 GPa. Compression was accommodated in the unit cell by a reduction of the c-axis between the planar DAAF layers, distortion of the β-angle of the monoclinic lattice, and an increase in intermolecular hydrogen bonding. Changes in the ring and -NH2 deformation modes and increased intermolecular hydrogen bonding interactions with compression suggest molecular reorganizations and electronic transitions at ∼ 5 GPa and ∼ 10 GPa that are accompanied by a shifting of the absorption band edge into the visible. A fourth-order Birch-Murnaghan fit to the room temperature isotherm afforded an estimate of the zero-pressure isothermal bulk modulus, K0 = 12.4 ± 0.6 GPa and its pressure derivative K0' = 7.7 ± 0.3.

Study Design: Retrospective review of prospectively collected databases., Objective: To compare 2 approaches for assessment of mortality associated with spine surgery., Summary of Background Data: The Scoliosis Research Society collects morbidity and mortality data from its members. Previously, this included details for all spine cases and all complications. To reduce time burden and improve compliance, collection was changed to focus on a few major complications (death, neurological deficit, and blindness) for specific deformity diagnoses (scoliosis, spondylolisthesis, and kyphosis) and only for cases with complications., Methods: Data were extracted from the Scoliosis Research Society from 2004-2007 (detailed system) and 2009-2011 (simplified system). As an anchor for comparison, mortality rates were compared between the systems., Results: Between 2009 and 2011, the number of deformity cases reported were 87,162, with 131 deaths (1.50/1000 cases). The mean age of these 131 patients was 50, mean American Society of Anesthesiologists grade was 2.8, 10% were smokers, and 18% had diabetes. Rates of death (per 1000 cases) were: idiopathic scoliosis (0.4), congenital scoliosis (1.3), neuromuscular scoliosis (3.6), other scoliosis (3.1), spondylolisthesis (0.6), and kyphosis (4.7). Common causes of mortality included respiratory (48), cardiac (32), sepsis (12), organ failure (9), and blood loss (7). Compared with the detailed system, the simplified system had greater surgeon compliance (79% vs. 62%, P < 0.001), greater number of deformity cases per reporting surgeon per year (139 vs. 90, P < 0.001), and modest but significantly lower mortality rates (1.50 vs. 1.80/1000 cases; P < 0.001). Causes of death were comparable between the 2 systems., Conclusion: On the basis of the simplified collection system, the rate of mortality for spinal deformity surgery was 1.50 per 1000 cases. Compared with the detailed system, the simplified system had significantly improved compliance and similar mortality rates. Although the simplified system is limited by less data collected, it achieves better compliance and may prove effective, especially if supplemented with focused data collection modules.

We present a Nested Markov chain Monte Carlo (NMC) scheme for building equilibrium averages based on accurate potentials such as density functional theory. Metropolis sampling of a reference system, defined by an inexpensive but approximate potential, was used to substantially decorrelate configurations at which the potential of interest was evaluated, thereby dramatically reducing the number needed to build ensemble averages at a given level of precision. The efficiency of this procedure was maximized on-the-fly through variation of the reference system thermodynamic state (characterized here by its inverse temperature β(0)), which was otherwise unconstrained. Local density approximation results are presented for shocked states of argon at pressures from 4 to 60 GPa, where-depending on the quality of the reference system potential-acceptance probabilities were enhanced by factors of 1.2-28 relative to unoptimized NMC. The optimization procedure compensated strongly for reference potential shortcomings, as evidenced by significantly higher speedups when using a reference potential of lower quality. The efficiency of optimized NMC is shown to be competitive with that of standard ab initio molecular dynamics in the canonical ensemble.

Background: Lateral mass screw fixation with plates or rods has become the standard method of posterior cervical spine fixation and stabilization for a variety of surgical indications. Despite ubiquitous usage, the safety and efficacy of this technique have not yet been established sufficiently to permit "on-label" U.S. Food and Drug Administration approval for lateral mass screw fixation systems. The purpose of this study was to describe the safety profile and effectiveness of such systems when used in stabilizing the posterior cervical spine., Methods: A systematic search was conducted in MEDLINE and the Cochrane Collaboration Library for articles published from January 1, 1980, to December 1, 2011. We included all articles evaluating safety and/or clinical outcomes in adult patients undergoing posterior cervical subaxial fusion utilizing lateral mass instrumentation with plates or rods for degenerative disease (spondylosis), trauma, deformity, inflammatory disease, and revision surgery that satisfied our a priori inclusion and exclusion criteria., Results: Twenty articles (two retrospective comparative studies and eighteen case series) satisfied the inclusion and exclusion criteria and were included. Both of the comparative studies involved comparison of lateral mass screw fixation with wiring and indicated that the risk of complications was comparable between treatments (range, 0% to 7.1% compared with 0% to 6.3%, respectively). In one study, the fusion rate reported in the screw fixation group (100%) was similar to that in the wiring group (97%). Complication risks following lateral mass screw fixation were low across the eighteen case series. Nerve root injury attributed to screw placement occurred in 1.0% (95% confidence interval, 0.3% to 1.6%) of patients. No cases of vertebral artery injury were reported. Instrumentation complications such as screw or rod pullout, screw or plate breakage, and screw loosening occurred in <1% of the screws inserted. Fusion was achieved in 97.0% of patients across nine case series., Conclusions: The risks of complications were low and the fusion rate was high when lateral mass screw fixation was used in patients undergoing posterior cervical subaxial fusion. Nerve root injury attributed to screw placement occurred in only 1% of 1041 patients. No cases of vertebral artery injury were identified in 758 patients. Screw or rod pullout, screw or plate breakage, and screw loosening occurred in <1% of the screws inserted.

Objective: Pedicle-based dynamic stabilization systems, in which semi-rigid rods or cords are used to restrict or control spinal segmental motion, aim to reduce or eliminate the drawbacks associated with rigid fusion. In this study, we analyzed the two-year clinical outcomes of patients treated with the NFlex (Synthes Spine, Inc.), a pedicle-based dynamic stabilization system., Methods: Five sites participated in a retrospective study of 72 consecutive patients who underwent NFlex stabilization. Of these 72 patients, 65 were available for 2-year follow-up. Patients were included based on the presence of degenerative disc disease (29 patients), degenerative spondylolisthesis (16 patients), lumbar stenosis (9 patients), adjacent segment degeneration (6 patients), and degenerative lumbar scoliosis (5 patients). The clinical outcome measures at each assessment were Visual Analogue Scale (VAS) to measure back pain, and Oswestry Disability Index (ODI) to measure functional status. Radiographic assessments included evidence of instrumentation failure or screw loosening., Results: Sixty-five patients (26 men and 39 women) with a mean age of 54.5 years were included. Mean follow-up was 25.6 months. The mean VAS score improved from 8.1 preoperatively to 3.8 postoperatively, representing a 53% improvement, and the ODI score from 44.5 to 21.8, representing a 51% improvement. Improvements in pain and disability scores were statistically significant. Three implant-related complications were observed., Conclusion: Posterior pedicle-based dynamic stabilization using the NFlex system seems effective in improving pain and functional scores, with sustained clinical improvement after two years. With appropriate patient selection, it may be considered an effective alternative to rigid fusion.

Objective: The goal of this study was to use mice expressing human tissue factor pathway inhibitor (TFPI) on α-smooth muscle actin (α-SMA)(+) cells as recipients of allogeneic aortas to gain insights into the cellular mechanisms of intimal hyperplasia (IH)., Methods and Results: BALB/c aortas (H-2(d)) transplanted into α-TFPI-transgenic (Tg) mice (H-2(b)) regenerated a quiescent endothelium in contrast to progressive IH seen in C57BL/6 wild-type (WT) mice even though both developed aggressive anti-H-2(d) alloresponses, indicating similar vascular injuries. Adoptively transferred Tg CD34(+) (but not CD34(-)) cells inhibited IH in WT recipients, indicating the phenotype of α-TFPI-Tg mice was due to these cells. Compared with syngeneic controls, endogenous CD34(+) cells were mobilized in significant numbers after allogeneic transplantation, the majority showing sustained expression of tissue factor and protease-activated receptor-1 (PAR-1). In WT, most were CD45(+) myeloid progenitors coexpressing CD31, vascular endothelial growth factor receptor-2 and E-selectin; 10% of these cells coexpressed α-SMA and were recruited to the neointima. In contrast, the α-SMA(+) human TFPI(+) CD34(+) cells recruited in Tg recipients were from a CD45(-) lineage. WT CD34(+) cells incubated with a PAR-1 antagonist or taken from PAR-1-deficient mice inhibited IH as Tg cells did., Conclusions: Specific inhibition of thrombin generation or PAR-1 signaling on α-SMA(+) CD34(+) cells inhibits IH and promotes regenerative repair despite ongoing immune-mediated damage.

An optimized variant of the nested Markov chain Monte Carlo [n(MC)(2)] method [J. Chem. Phys. 130, 164104 (2009)] is applied to fluid N(2). In this implementation of n(MC)(2), isothermal-isobaric (NPT) ensemble sampling on the basis of a pair potential (the "reference" system) is used to enhance the efficiency of sampling based on Perdew-Burke-Ernzerhof density functional theory with a 6-31G(*) basis set (PBE6-31G(*), the "full" system). A long sequence of Monte Carlo steps taken in the reference system is converted into a trial step taken in the full system; for a good choice of reference potential, these trial steps have a high probability of acceptance. Using decorrelated samples drawn from the reference distribution, the pressure and temperature of the full system are varied such that its distribution overlaps maximally with that of the reference system. Optimized pressures and temperatures then serve as input parameters for n(MC)(2) sampling of dense fluid N(2) over a wide range of thermodynamic conditions. The simulation results are combined to construct the Hugoniot of nitrogen fluid, yielding predictions in excellent agreement with experiment.

Building on the work of Iftimie et al. [J. Chem. Phys. 113, 4852 (2000)] and Gelb [J. Chem. Phys. 118, 7747 (2003)], Boltzmann sampling of an approximate potential (the "reference" system) is used to build a Markov chain in the isothermal-isobaric ensemble. At the end points of the chain, the energy is evaluated at a more accurate level (the "full" system) and a composite move encompassing all of the intervening steps is accepted on the basis of a modified Metropolis criterion. For reference system chains of sufficient length, consecutive full energies are statistically decorrelated and thus far fewer are required to build ensemble averages with a given variance. Without modifying the original algorithm, however, the maximum reference chain length is too short to decorrelate full configurations without dramatically lowering the acceptance probability of the composite move. This difficulty stems from the fact that the reference and full potentials sample different statistical distributions. By manipulating the thermodynamic variables characterizing the reference system (pressure and temperature, in this case), we maximize the average acceptance probability of composite moves, lengthening significantly the random walk between consecutive full energy evaluations. In this manner, the number of full energy evaluations needed to precisely characterize equilibrium properties is dramatically reduced. The method is applied to a model fluid, but implications for sampling high-dimensional systems with ab initio or density functional theory potentials are discussed.

The full multiple spawning (FMS) method has been developed to simulate quantum dynamics in the multistate electronic problem. In FMS, the nuclear wave function is represented in a basis of coupled, frozen Gaussians, and a "spawning" procedure prescribes a means of adaptively increasing the size of this basis in order to capture population transfer between electronic states. Herein we detail a new algorithm for specifying the initial conditions of newly spawned basis functions that minimizes the number of spawned basis functions needed for convergence. "Optimally" spawned basis functions are placed to maximize the coupling between parent and child trajectories at the point of spawning. The method is tested with a two-state, one-mode avoided crossing model and a two-state, two-mode conical intersection model.

We discuss the connectivity of intersection spaces and the role of minimal energy points within these intersection spaces (minimal energy conical intersections or MECIs) in promoting nonadiabatic transitions. We focus on malonaldeyde as a specific example, where there is a low-lying three-state conical intersection. This three-state intersection is the global minimum on the bright excited electronic state, but it plays a limited role in population transfer in our ab initio multiple spawning (AIMS) simulations because the molecule must traverse a series of two-state conical intersections to reach the three-state intersection. Due to the differences in seam space dimensionality separating conventional (two-state) and three-state intersections, we suggest that dynamical effects arising directly from a three-state intersection may prove difficult to observe in general. We also use a newly developed method for intersection optimization with geometric constraints to demonstrate the connectivity of all the stationary points in the intersection spaces for malonaldehyde. This supports the conjecture that all intersection spaces are connected, and that three-state intersections play a key role in extending this connectivity to all pairs of states, e.g. the S1/S0 and S2/S1 intersection spaces.

Background: Complications associated with rigid posterior instrumented fusions of the lumbar spine include pseudarthrosis, accelerated adjacent-segment disease, hardware failure, and iatrogenic fixed sagittal imbalance. Posterior pedicle screw/rod-based dynamic stabilization systems, in which semirigid rods or cords are used to restrict or control, rather than completely eliminate spinal segmental motion, aim to reduce or eliminate these fusion-associated drawbacks. In this study, we analyzed the early radiographic and clinical outcomes of patients treated with the NFix II System (N Spine, Inc., San Diego, California), a novel pedicle screw/ rod-based system used as a nonfusion posterior dynamic stabilization system, and compared our results to those of similar systems currently in use., Methods: Seven sites participated in a retrospective assessment of 40 consecutive patients who underwent dynamic stabilization of the lumbar spine with the NFix II System at a single level. (One patient underwent 2 single-level dynamic constructs at noncontiguous levels (L3-4 and L5-S1).) Patients were included based on the presence of spinal stenosis, degenerative spondylolisthesis, adjacent segment degeneration, recurrent disc herniation, symptomatic degenerative disc disease, and degenerative scoliosis requiring dynamic stabilization at 1 level with or without instrumented rigid fusion at a contiguous level. Participants were evaluated preoperatively, with planned postoperative assessments at 3 and 6 weeks (1 center assessed patients at 4 weeks), 3 months, 6 months, and 12 months. The primary clinical outcome measures at each assessment were visual analogue scale (VAS) scores to measure back pain, and Oswestry Disability Index (ODI)(1) scores to measure function. Radiographic outcome measurements included evidence of instrumentation failure and range of motion (ROM) based on postoperative flexion-extension radiographs at 3, 6, and 12 months., Results: Forty patients (15males, 25 females) with a mean age of 55 years (range 21-81) were included. Average follow-up was 8.1 months (range 6-12). The mean VAS score improved from 7.6 preoperatively to 3.3 postoperatively (P < .001), and the ODI score from 47.3 to 22.8 (P < .001). Eighty percent of patients were severely disabled or worse (ODI ≥ 41) preoperatively, which was reduced to 13% postoperatively. Of the 10 patients with more than 6 months' follow-up, only 4 demonstrated adequate flexion/extension effort. ROM measurements in those 4 patients showed that on average 53% of preoperative segmental motion was retained at the dynamically stabilized level 6 months postoperatively. There were no instrumentation-related complications., Conclusions: Results of this limited study indicate that the NFix II System when used as a nonfusion device for dynamic stabilization produces significant improvements in pain and function at short-term follow-up with outcomes comparable to other dynamic stabilization systems. The use of this system was not associated with an increased risk of instrumentation failure. The small number of patients with postoperative severe disability or worse compares favorably to long-term published data on posterolateral fusion. Lastly, in this small sample, ROM was preserved at 6-month follow-up., Clinical Relevance: Posterior pedicle screw/rod dynamic stabilization using the NFix II System seems very effective in improving pain and function scores, at least in the short term (mean postoperative ODI of 22.8). Preservation of ROM is also possible. Longerterm follow-up is necessary to assess sustained clinical improvement, hardware complications, and maintenance in segmental ROM. The NFix II System may be considered an effective alternative to existing dynamic stabilization systems. This device is cleared by the US Food and Drug Administration for use as an adjunct to fusion and has the European CE Marking for use in both fusion and nonfusion applications.

We introduce a new method for optimizing minimal energy conical intersections (MECIs), based on a sequential penalty constrained optimization in conjunction with a smoothing function. The method is applied to optimize MECI geometries using the multistate formulation of second-order multireference perturbation theory (MS-CASPT2). Resulting geometries and energetics for conjugated molecules including ethylene, butadiene, stilbene, and the green fluorescent protein chromophore are compared with state-averaged complete active space self-consistent field (SA-CASSCF) and, where possible, benchmark multireference single- and double-excitation configuration interaction (MRSDCI) optimizations. Finally, we introduce the idea of "minimal distance conical intersections", which are points on the intersection seam that lie closest to some specified geometry such as the Franck-Condon point or a local minimum on the excited state.

Femtosecond time-resolved photoelectron spectroscopy and high-level theoretical calculations were used to study the effects of methyl substitution on the electronic dynamics of the alpha,beta-enones acrolein (2-propenal), crotonaldehyde (2-butenal), methylvinylketone (3-buten-2-one), and methacrolein (2-methyl-2-propenal) following excitation to the S2(pipi*) state at 209 and 200 nm. We determine that following excitation the molecules move rapidly away from the Franck-Condon region, reaching a conical intersection promoting relaxation to the S1(npi*) state. Once on the S1 surface, the trajectories access another conical intersection, leading them to the ground state. Only small variations between molecules are seen in their S2 decay times. However, the position of methyl group substitution greatly affects the relaxation rate from the S1 surface and the branching ratios to the products. Ab initio calculations used to compare the geometries, energies, and topographies of the S1/S0 conical intersections of the molecules are not able to satisfactorily explain the variations in relaxation behavior. We propose that the S1 lifetime differences are caused by specific dynamical factors that affect the efficiency of passage through the S1/S0 conical intersection.

We present the first calculations of excited-state dynamics using ab initio molecular dynamics with a multireference perturbation theory description of the electronic structure. The new AIMS-CASPT2 method is applied to a paradigmatic excited-state intramolecular proton-transfer reaction in methyl salicylate, and the results are compared with previous ultrafast spectroscopic experiments. Agreement of AIMS-CASPT2 and experimental results is quantitative. The results demonstrate that the lack of an observed isotope effect in the reaction is due to multidimensionality of the reaction coordinate, which largely involves heavy-atom bond alternation instead of proton transfer. Using the dynamics results as a guide, we also characterize relevant minima on the ground and first singlet excited state using CASPT2 electronic structure theory. We further locate an S1/S0 minimal energy conical intersection, whose presence explains experimental observations of a sharp decrease in fluorescence quantum yield at excitation energies more than 1,300 cm-1 above the excited-state origin.

Study Design: The Morbidity and Mortality database of the Scoliosis Research Society (SRS) was queried as to the incidence and type of complications as reported by its members for the treatment of adolescent idiopathic scoliosis (AIS) with spinal fusion and instrumentation procedures regarding surgical approach (anterior, posterior, or combined anterior-posterior) during a recent 3-year period., Objective: To evaluate the incidence of surgeon-reported complications in a large series of spinal fusions with instrumentation for a single spinal deformity diagnosis and age group regarding surgical approach., Summary of Background Data: The SRS has been collecting morbidity and mortality data from its members since its formation in 1965 with the intent of using these data to assess the complications and adverse outcomes (death and/or spinal cord injury) of surgical treatment for spinal deformity. Surgical approaches to the management of treatment of AIS have a measurable impact on efficacy of correction, levels fused, and operative morbidity. However, there is a lack of consensus on the choice of surgical approach for the treatment of spinal deformity., Methods: Of the 58,197 surgical cases submitted by members of the SRS in the years 2001, 2002, and 2003, 10.9% were identified as having had anterior, posterior, or combined spinal fusion with instrumentation for the diagnosis of AIS, and comprised the study cohort. All reported complications were tabulated and totaled for each of the 3 types of procedures, and statistical analysis was conducted., Results: Complications were reported in 5.7% of the 6334 patients in this series. Of the 1164 patients who underwent anterior fusion and instrumentation, 5.2% had complications, of the 4369 who underwent posterior instrumentation and fusion, 5.1% had complications, and of the 801 who underwent combined instrumentation and fusion, 10.2% had complications. There were 2 patients (0.03%) who died of their complications. There was no statistical difference in overall complication rates between anterior and posterior procedures. However, the difference in complication rates between anterior or posterior procedures compared to combined procedures was highly significant (P < 0.0001). The differences in neurologic complication rates between combined and anterior procedures, as well as combined and posterior procedures were also highly statistically significant (P < 0.0001), but not between anterior and posterior procedures., Conclusions: This study shows that complication rates are similar for anterior versus posterior approaches to AIS deformity correction. Combined anterior and posterior instrumentation and fusion has double the complication rate of either anterior or posterior instrumentation and fusion alone. Combined anterior and posterior instrumentation and fusion also has a significantly higher rate of neurologic complications than anterior or posterior instrumentation and fusion alone.

Excited-state potential energy surface (PES) characterization is carried out at the CASSCF and MRSDCI levels, followed by ab initio dynamics simulation of excited-state intramolecular proton transfer (ESIPT) on the S2(pipi*) state in malonaldehyde. The proton-transfer transition state lies close to an S2/S1 conical intersection, leading to substantial coupling of proton transfer with electronic relaxation. Proton exchange proceeds freely on S2, but its duration is limited by competition with twisting out of the molecular plane. This rotamerization pathway leads to an intersection of the three lowest singlet states, providing the first detailed report of ab initio dynamics around a three-state intersection (3SI). There is a significant energy barrier to ESIPT on S1, and further pyramidalization of the twisted structure leads to the minimal energy S1/S0 intersection and energetic terminal point of excited-state dynamics. Kinetics and additional mechanistic details of these pathways are discussed. Significant depletion of the spectroscopic state and recovery of the ground state is seen within the first 250 fs after photoexcitation.

Study Design: Twenty-seven patients underwent instrumented transforaminal lumbar interbody fusion (TLIF) procedures using bioresorbable implants as interbody spacers. The greater than 2-year clinical and radiographic results of this series are presented along with as a review of relevant preclinical and preliminary clinical studies of bioresorbables., Objective: To determine the clinical suitability of bioresorbable implants used as interbody spacers in spinal fusion surgery applications, particularly in the TLIF procedure., Summary of Background Data: Bioresorbable technology has been in clinical use by surgeons of a variety of specialties for over 35 years. The use of bioresorbable implants in spine surgery, however, has only been widely investigated in the last several years. The use of slowly degrading bioresorbable implants has the potential for load sharing during fusion when used for interbody applications, retaining imaging quality after fusion, obviating later implant removal, providing biologic barriers as well as other various applications. Animal studies and early clinical series with the use of these materials for a variety of indications have been encouraging., Methods: This study evaluates the use of bioresorbable polymer spacers manufactured with a 70:30 copolymer of poly-L-lactide and D,L-lactide as interbody spacers in 27 of 31 patients with 2 years or more follow-up who underwent instrumented TLIF for primarily degenerative indications., Results: At a mean of 31.9 months follow-up, 25 patients (92.6%) were judged to have solid fusions and 22 patients (81.5%) had good to excellent results. Three patients (11.1%) experienced complications, none of which were directly or indirectly attributable to the use of the bioresorbable polymer implant. Only one implant in 1 patient (3.7%) demonstrated mechanical failure on insertion, and that patient exhibited no clinical sequelae., Conclusions: Bioresorbable implants have significant potential for use in spine surgery. This potential is realized in this first published clinical series using bioresorbable implants as interbody spacers with a minimum follow-up of 2 years, significantly exceeding the biologic "life expectancy" (12-18 months) of the implant material. Both the clinical and radiographic results of this study support the use of interbody devices manufactured from bioresorbable polymers for structural interbody support in the TLIF procedure.

We demonstrate the existence of a simultaneous degeneracy (not required by symmetry) of three electronic states in malonaldehyde. This is one of the first reports of such a triple degeneracy involving S0, S1, and S2 in a molecule with a closed-shell ground state. We further report on a two-state S2/S1 conical intersection which is higher in energy than the three-state intersection, but closer to the Franck-Condon point. First-principles quantum dynamics calculations of the photochemistry after excitation to S2 show that there is a competition between these intersections, with more than half of the population decaying to S1 through the higher energy S2/S1 intersection. Surprisingly, much of the population which makes it to the triple degeneracy point is not funneled directly to S0, but rather remains trapped on S1. We attribute this to the large dimensionality of the branching plane at a three-state intersection (the degeneracy is lifted along at least five distinct molecular displacements).

Object. The purpose of this study was to evaluate the clinical and radiographic results in 31 patients from one center who underwent instrumented transforaminal lumbar interbody fusion (TLIF) for primarily degenerative indications. Methods. Bioabsorbable polymer spacers manufactured with a copolymer of 70:30 poly(L-lactide-co-D,L-lactide) and filled with iliac crest autograft bone were used for the TLIF procedure. In this paper the details of this procedure, intermediate (1- to 2-year) clinical and radiographic outcomes, and the basic science and rationale for the use of bioabsorbable polymers are discussed. At a mean of 18.4 months of follow up, 30 patients (96.8%) were judged to have attained solid fusions and 25 patients (81%) had good to excellent results. Three patients (9.7%) experienced complications, none of which were directly or indirectly attributable to the use of the bioabsorbable polymer implant. Only one implant in one patient (3.2%) demonstrated mechanical failure on insertion, and that patient experienced no clinical sequelae. Conclusions. This is the first clinical series to be published in which the mean follow-up duration equals or exceeds the biological life expectancy of this material (12-18 months). Both the clinical and radiographic results of this study support the use of interbody devices manufactured from biodegradable polymers for structural interbody support in the TLIF procedure.

Object: Sixty patients underwent instrumentation-assisted posterior transforaminal lumbar interbody fusion (TLIF) with resorbable polymer cages and autograft bone for degenerative disease. This article discusses the technique of TLIF and its early outcomes., Methods: Although the follow-up period is short and results are preliminary, no adverse events or complications were attributed to the resorbable polymer., Conclusions: Further multicenter clinical studies are underway with a minimum 2-year follow-up period chosen as an endpoint to provide insight as to the future of biodegradable polymers as spinal interbody devices.

Sixty patients from two centers have undergone instrumented transforaminal posterior lumbar interbody fusion (TLIF) with bioresorbable polymer cages and autograft bone for degenerative indications. This article discusses the technique of TLIF and its early outcomes. Although follow-up is short and results are preliminary, no adverse events or complications may be attributed to the bioresorbable polymer. Further multicenter clinical studies are underway with a minimum of 2 years of follow-up chosen as an endpoint to provide insight as to the future of biodegradable polymers as spinal interbody devices.

Study Design: A prospective evaluation of the clinical and radiographic outcomes of 71 patients who underwent lumbar fusion, with or without transpedicular instrumentation. The patients completed a questionnaire that determined pain relief, medication use, return to work, and overall satisfaction with surgery., Objectives: To explore the effect, if any, of instrumentation on the outcome of lumbar fusion surgery, according to reports of the patients, and whether there is a correlation between the radiographic determination of a solid fusion and the same patient-reported outcome., Summary of Background Data: The literature on this topic reports pseudarthrosis rates from 0% to 57% and good to excellent results from 56% to 95%. These studies provide no clear-cut recommendations concerning the effect of added lumbar instrumentation on patient-reported outcome in a prospective manner using concurrent control subjects., Methods: The patients were randomized to groups with and without instrumentation after deciding to undergo a lumbar fusion and consenting to enter the study. Radiographs were obtained and questionnaires filled out at 6 weeks, 6 months, 1 year, and 2 years after surgery., Results: There was no statistical difference in patient-reported outcome between the two groups. There was a slight nonsignificant trend toward increased radiographic fusion rate in the group with instrumentation that did not correlate with an increased patient-reported improvement rate., Conclusions: These results do not provide data that indicate a benefit in outcome from added instrumentation in elective lumbar fusions.

Fifty-six mature beagles underwent lumbar spine destabilization, followed by fusion using four techniques. Spinal cord neuropathologic analysis was carried out to determine the number of abnormalities within each group. Group I (n = 14) had posterolateral bone grafting without instrumentation. Group IIa (n = 14) had Cotrel-Dubousset (CD) pedicle screws and rods. Group IIb (n = 14) had Steffee pedicle screws and plates. Group III (n = 14) had sublaminar wires and rods. All of the animals remained clinically neurologically normal throughout the 6 months of the study. The incidence of moderate to severe neuropathologic changes was 21% in Group I, 18% in Group II, and 64% in Group III. Thus, a significantly higher percentage of neuropathologic abnormalities occurred with sublaminar instrumentation than with no instrumentation (p = 0.027), or with transpedicular instrumentation (p = 0.027). In this controlled animal study, the theoretical advantage of pedicle screws, which should not violate the spinal canal, over sublaminar devices, which must enter the canal, was confirmed.