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Retrospective cohort study.Determine whether screws per level and rod material/diameter are associated with incidence of proximal junctional kyphosis (PJF).PJF is a common and particularly adverse complication of adult spinal deformity (ASD) surgery. There is evidence that the rigidity of posterior spinal constructs may impact risk of PJF.Patients with ASD and 2-year minimum follow-up were included. Only patients undergoing primary fusion of more than or equal to five levels with lower instrumented vertebrae (LIV) at the sacro-pelvis were included. Screws per level fused was analyzed with a cutoff of 1.8 (determined by receiver operating characteristic curve (ROC) analysis). Multivariable logistic regression was utilized, controlling for age, body mass index (BMI), 6-week postoperative change from baseline in lumbar lordosis, number of posterior levels fused, sex, Charlson comorbidity index, approach, osteotomy, upper instrumented vertebra (UIV), osteoporosis, preoperative TPA, and pedicle screw at the UIV (as opposed to hook, wire, etc.).In total, 504 patients were included. PJF occurred in 12.7%. The mean screws per level was 1.7, and 56.8% of patients had less than 1.8 screws per level. No differences were observed between low versus high screw density groups for T1-pelvic angle or magnitude of lordosis correction (both P 0.15). PJF occurred in 17.0% versus 9.4% of patients with more than or equal to 1.8 versus less than 1.8 screws per level, respectively (P 0.05). In multivariable analysis, patients with less than 1.8 screws per level exhibited lower odds of PJF (odds ratio (OR) 0.48, P 0.05), and a continuous variable for screw density was significantly associated with PJF (OR 3.87 per 0.5 screws per level, P 0.05). Rod material and diameter were not significantly associated with PJF (both P 0.1).Among ASD patients undergoing long-segment primary fusion to the pelvis, the risk of PJF was lower among patients with less than 1.8 screws per level. This finding may be related to construct rigidity. Residual confounding by other patient and surgeon-specific characteristics may exist. Further biomechanical and clinical studies exploring this relationship are warranted.Level of Evidence: 3.

Objective Patients with ASD show complex and highly variable disease. The decision to manage patients operatively is largely subjective and varies based on surgeon training and experience. We sought to develop models capable of accurately discriminating between patients receiving operative versus nonoperative treatment based only on baseline radiographic and clinical data at enrollment. Methods This study was a retrospective analysis of a multicenter consecutive cohort of patients with ASD. A total of 1503 patients were included, divided in a 70:30 split for training and testing. Patients receiving operative treatment were defined as those undergoing surgery up to 1 year after their baseline visit. Potential predictors included available demographics, past medical history, patient-reported outcome measures, and premeasured radiographic parameters from anteroposterior and lateral films. In total, 321 potential predictors were included. Random forest, elastic net regression, logistic regression, and support vector machines (SVMs) with radial and linear kernels were trained. Results Of patients in the training and testing sets, 69.0% (n = 727) and 69.1% (n = 311), respectively, received operative management. On evaluation with the testing dataset, performance for SVM linear (area under the curve =0.910), elastic net (0.913), and SVM radial (0.914) models was excellent, and the logistic regression (0.896) and random forest (0.830) models performed very well for predicting operative management of patients with ASD. The SVM linear model showed 86% accuracy. Conclusions This study developed models showing excellent discrimination (area under the curve >0.9) between patients receiving operative versus nonoperative management, based solely on baseline study enrollment values. Future investigations may evaluate the implementation of such models for decision support in the clinical setting.

Sexual function is an important factor contributing to quality of life. Adult spinal deformity (ASD) patients may have sexual limitations due to lumbar spinal stiffness that may be affected by long-segment fusion.This study utilized a multicenter, prospectively defined, consecutive cohort of ASD patients. The primary outcome in this study was the Lumbar Stiffness Disability Index (LSDI) question 10: "Choose the statement that best describes the effect of low back stiffness on your ability to engage in sexual intercourse".In total, 368 patients were included in this study, including 76 men and 292 women, of which 80.7% (n = 293) underwent 9 or more level fusion and 74.4% (n = 270) had pelvic fixation. Baseline LSDI sexual function scores averaged 1.7 (SD 1.3), which improved to 1.3 (SD 1.2) at 2-year follow-up (P = 0.0008). After adjusting for confounding factors, worse LSDI sexual function score was strongly associated with worse Oswestry Disability Index, Scoliosis Research Society-22r total, and SF-36 Physical Component Summary and Mental Component Summary scores at both baseline and 2-year follow-up (p0.05 for all comparisons). Predictors of poorer baseline sexual function included older age, increased SVA, and increased back pain (p0.05 for all comparisons). Predictors of improvement in sexual function at 2-year follow-up included sagittal vertical axis improvement (P = 0.0032) and decreased postoperative back pain (P0.0001).This study found that sexual dysfunction scores due to lumbar stiffness significantly improved after surgery for ASD. Additionally, lumbar stiffness-related sexual dysfunction is strongly related to overall outcome measured by Oswestry Disability Index and Scoliosis Research Society-22r total score, highlighting the importance of sexual health on overall outcome in ASD patients.

Background Spinal epidural abscess is a rare pathology with an incidence that has tripled in the past 2 decades. Ventral cervical epidural abscesses (vCEA) of the cervical spine pose particular treatment challenges because of the anatomical location. The aim of this report is to identify trends in the surgical management of these patients and to determine whether concomitant spondylodiscitis warrants fusion at the index surgery. Methods Patients presenting to a quaternary care institution from January 2009 to December 2018 with isolated vCEA were identified. Patients were excluded if they had dorsal or circumferential epidural abscesses. Clinical and radiographic data were collected. Patients with vCEA were stratified by the presence or absence of spondylodiscitis upon presentation. Clinical outcomes analyzed included neurological sequelae and the need for revision surgery. Results During the 10-year study period, 36 patients presented with symptomatic isolated vCEA and constituted the study cohort; 16 (44%) had concurrent spondylodiscitis. All 36 patients underwent surgical decompression; the initial surgical approach was anterior-only for 7 patients (19%), posterior-only for 27 patients (75%), and and a combined approach for 2 patients (6%). Four patients from the total cohort (11%) ultimately required a revision operation; all 4 were from the subset with concurrent spondylodiscitis (25% vs. 0%, P = 0.03). Conclusions vCEA can be evacuated safely and effectively by a variety of strategies in patients with neurologic deficits. Concomitant spondylodiscitis with cervical epidural abscess may warrant instrumented fusion as part of the initial surgical strategy.

OBJECTIVE Cage subsidence is a well-known phenomenon after lateral lumbar interbody fusion (LLIF), occurring in 10%–20% of cases. A 3D-printed porous titanium (pTi) cage has a stiffness that mimics the modulus of elasticity of native vertebrae, which reduces stress at the bone-hardware interface, lowering the risk of subsidence. In this study, the authors evaluated their institutional rate of subsidence and resultant reoperation in patients who underwent LLIF using a 3D-printed pTi interbody cage. METHODS This is a retrospective case series of consecutive adult patients who underwent LLIF using pTi cages from 2018 to 2020. Demographic and clinical characteristics including age, sex, bone mineral density, smoking status, diabetes, steroid use, number of fusion levels, posterior instrumentation, and graft size were collected. The Marchi subsidence grade was determined at the time of last follow-up. Outcome measures of interest were subsidence and resultant reoperation. Univariable logistic regression analysis was performed to assess the extent to which clinical and operative characteristics were associated with Marchi grade I–III subsidence. Significance was assessed at p < 0.05. RESULTS Fifty-five patients (38 with degenerative disc disease and 17 with adult spinal deformity) were treated with 97 pTi interbody cages with a mean follow-up of 18 months. The mean age was 63.6 ± 10.1 years, 60% of patients were female, and 36% of patients had osteopenia or osteoporosis. Patients most commonly underwent single-level LLIF (58.2%). Sixteen patients (29.1%) had posterior instrumentation. The subsidence grade distribution was as follows: 89 (92%) grade 0, 5 (5%) grade I, 2 (2%) grade II, and 1 (1%) grade III. No patients who were active or prior smokers and no patients with posterior instrumentation experienced graft subsidence. No clinical or operative characteristics were significantly associated with graft subsidence. One patient (1.8%) required reoperation because of subsidence. CONCLUSIONS In this institutional case series, subsidence of pTi intervertebral cages after LLIF occurred in 8% of operated levels, 3% of which were grade II or III. Only 1 patient required reoperation. These reported rates are lower than those reported for polyetheretherketone implants. Further studies are necessary to compare the impact of these cage materials on subsidence after LLIF.

The Lumbar Stiffness Disability Index (LSDI) assesses impact of lumbar stiffness on activities of daily living. We hypothesized that patients60 years old would perceive greater lumbar stiffness-related functional limitation following fusion for adult spinal deformity.Patients completed the LSDI and Scoliosis Research Society 22 Questionnaire, Revised (SRS-22r) preoperatively and at 2 years postoperatively. The primary independent variable was patient age60 versus ≥60. Multivariable regression analyses were used.Analysis included 267 patients. Patients60 years old (51.3%) and ≥60 years old (48.7%) were evenly represented. In bivariable analysis, patients age60 exhibited lower LSDI at baseline versus patients age ≥60 (25.7 vs. 35.5, β -9.8, P0.0001), but a directionally smaller difference at 2 years (26.4 vs. 32.3, β -5.8, P = 0.0147). LSDI was associated with lower SRS-22r total score among both age groups at baseline and 2 years (all P0.0001); the association was stronger among patients age60 versus ≥60 at 2 years. LSDI was associated with SRS-22r satisfaction scores at 2 years among patients age60 (P0.0001), but not patients age ≥60 (P = 0.2250). The difference in SRS-22r satisfaction per unit LSDI between patients60 years old and ≥60 years old was significant (P = 0.0021).Among patients with adult spinal deformity managed operatively, higher LSDI was associated with inferior SRS-22r total score and satisfaction at 2 years postoperatively. The association between increased LSDI and worse patient-reported outcome measures was greater among patients age60 versus ≥60. Preoperative counseling is needed for patients age60 undergoing adult spinal deformity surgery regarding effects that lumbar stiffness may have on postoperative function and satisfaction.

The dual-hormone hypothesis posits that social status is positively related to testosterone levels when cortisol levels are relatively low and negatively related to testosterone levels when cortisol is high. In the present study, we test this hypothesis with Olympic-level women athletes using a novel status-hierarchy generation task that establishes rank-order among teammates along three dimensions: leadership ability, popularity, and skill. Participants completed the hierarchy generation task and then, testosterone and cortisol levels were obtained from samples provided on a neutral-day baseline and immediately prior to competing in an international match. The interaction between cortisol and testosterone predicted social status among teammates for both baseline and pre-match samples. Specifically, there was a negative association between testosterone and status for those who were relatively high in cortisol. These results provide support for the dual-hormone hypothesis using a new, ecologically valid method for determining rank-order among members of a social group, in a special population of women athletes competing at the highest level of their sport.

Retrospective review.Develop a simplified frailty index for cervical deformity (CD) patients.To improve preoperative risk stratification for surgical CD patients, a CD frailty index (CD-FI) incorporating 40 health deficits was developed. While novel, the CD-FI is clinically impractical due to the large number of factors needed for its calculation. To increase clinical utility, a simpler, modified CD-FI (mCD-FI) is necessary.CD patients (C2-C7 Cobb10°, CL10°, cSVA4 cm, or CBVA25°)18 year with preoperative CD-FI component factors. Pearson bivariate correlation assessed relationships between component deficits of the CD-FI and overall CD-FI score. Top deficits contributing to CD-FI score were included in multiple stepwise regression models. Deficits from model with largest R were dichotomized, and the mean score of all deficits calculated, resulting in mCD-FI score from 0 to 1. Patients were stratified by mCD-FI: Not Frail (NF,0.3), Frail (0.3-0.5), Severely Frail (SF,0.5). Means comparison tests established correlations between frailty category and clinical outcomes.Included: 121 CD patients (61 ± 11 yr, 60%F). Multiple stepwise regression models identified 15 deficits as responsible for 86% of the variation in CD-FI; these factors were used to construct the mCD-FI. Overall, mean mCD-FI was 0.31 ± 0.14. Breakdown of patients by mCD-FI category: NF: 47.9%, Frail: 46.3%, SF: 5.8%. Compared with NF and Frail, SF patients had the longest inpatient hospital stays (P = 0.042), as well as greater baseline neck pain (P = 0.033), inferior Neck Disability Index scores (P0.001) and inferior EQ-5D scores (P 0.001). Frail patients had higher odds of superficial infection (OR:1.1[1.0-1.2]), and SF patients had increased odds of mortality (OR:8.3[1.3-53.9]).Increased frailty, assessed by mCD-FI, correlated with increased length of stay, neck pain, and decreased health-related quality of life. Frail patients were at greater risk for infection, and severely frail patients had greater odds of mortality. This relationship between frailty and clinical outcomes suggests that mCD-FI offers clinical utility as a preoperative risk stratification tool.3.

Objectives: The rates of arthrodesis performed in the United States and globally have increased tremendously in the last 10–15 years. Amongst the most devastating complications are neurological deficits including spinal cord injury, nerve root irritation, and cauda equine syndrome. The primary purpose of this study is to understand the risk factors for perioperative neurological deficits in patients undergoing thoracolumbar fusion. Patients and methods: Data from the Nationwide Inpatient Sample between the years of 1999–2011 was analyzed. Patients were between the ages of 18 and 80 who had thoracolumbar fusion. Excluded were patients who underwent the procedure as a result of trauma or a malignancy. A list of covariates, including demographic variables, preoperative and postoperative variables that are known to increase the risk of perioperative neurological deficits were compiled. Statistical analysis utilized univariate and multivariate logistic regression for comparisons between these covariates and the proposed outcomes. Results: The analysis of 37,899 patients yielded an overall rate of perioperative neurological deficits and mortality of 1.20% and 0.27%, respectively. Risk factors for perioperative neurological deficits included increasing age (OR 1.023 95% CI 1.018–1.029), Van Walraven 5–14 (OR 1.535 95% CI 1.054–2.235), and preoperative paralysis (OR 2.551 95% CI 1.674–3.886). Furthermore, the data showed that being 65 years old or older doubled the risk for perioperative deficit (OR 1.655, CI 1.248–2.194, p

BACKGROUND Lateral (ie, coronal) vertebral listhesis may contribute to disability in adult scoliosis patients. OBJECTIVE To assess for a correlation between lateral listhesis and disability among patients with adult scoliosis. METHODS This was a retrospective multi-center analysis of prospectively collected data. Patients eligible for a minimum of 2-yr follow-up and with coronal plane deformity (defined as maximum Cobb angle ≥20o) were included (n = 724). Outcome measures were Oswestry Disability Index (ODI) and leg pain numeric scale rating. Lateral thoracolumbar listhesis was measured as the maximum vertebral listhesis as a percent of the superior endplate across T1-L5 levels. Linear and logistic regression was utilized, as appropriate. Multivariable analyses adjusted for demographics, comorbidities, surgical invasiveness, maximum Cobb angle, and T1-PA. Minimally clinically important difference (MCID) in ODI was defined as 12.8. RESULTS In total, 724 adult patients were assessed. The mean baseline maximum lateral thoracolumbar listhesis was 18.3% (standard deviation 9.7%). The optimal statistical grouping for lateral listhesis was empirically determined to be none/mild (

Background Knowledge of free-hand screw technique remains critical to adequately train neurosurgical residents. The purpose of this study was to evaluate the accuracy of screw placement via the free-hand technique in lumbar, thoracic, and cervical spine by neurosurgical residents completing an enfolded spine fellowship. Methods Medical records of all patients who underwent free-hand screw placement at all spinal levels over a 6-month period by senior neurosurgical residents enrolled in an in-folded spine fellowship were retrospectively reviewed. Postoperative CT images were assessed for presence and direction of cortical breach. Results Twenty-six patients underwent 162 free-hand screw placements. The most commonly placed screws were cervical lateral mass screws (n = 69), thoracic (n = 41), and lumbar pedicle screws (n = 41). The most common indication for surgery was deformity (n = 22), followed by infection (n = 2) and trauma (n = 2). Fifty-five breaches were identified in 44 (27 %) screws placed in 21 patients (81 %). Anterior breach was identified in 22 cases (40.0 %), lateral in 12 (23.6 %), superior in 7 (12.7 %), and inferior in 7 (12.7 %), and medial in 6 (10.9 %). The most common level of breach was observed in cervical lateral mass screws (n = 19, 43 %) and least common in C2 pars screws (n = 1, 2%). With an average length of follow up of 12.1 ± 7.7 months of follow-up, no clinical sequalae of screw breach was observed. Conclusions Despite the high prevalence of screw breach using the free-hand technique by neurosurgical residents, the absence of clinical sequelae implies safety and emphasizes the importance of early exposure to this technique during neurosurgical residency training.

OBJECTIVE Patient feedback surveys provide important insight into patient outcomes, satisfaction, and perioperative needs. Recent critiques have questioned provider-initiated surveys and their capacity to accurately gauge patient perspectives due to intrinsic biases created by question framing. In this study, the authors sought to evaluate provider-independent, patient-controlled social media Instagram posts in order to better understand the patient experience following scoliosis correction surgery. METHODS Twitter and Instagram were queried for posts with two tagged indicators, #scoliosissurgery or @scoliosissurgery, resulting in no relevant Twitter posts and 25,000 Instagram posts. Of the initial search, 24,500 Instagram posts that did not directly involve the patient’s own experience were eliminated. Posts were analyzed and coded for the following criteria: the gender of the patient, preoperative or postoperative timing discussed in the post, and classified themes related to the patient’s experiences with scoliosis correction surgery. RESULTS Females made 87.6% of the Instagram posts about their experience following scoliosis correction surgery. The initial postoperative stage of surgery was mentioned in 7.6% of Instagram posts. The most common theme on Instagram involved offering or seeking online support from other patients, which constituted 85.2% of all posts. Other common themes included concern about the surgical scar (31.8%), discussing the results of treatment (28.8%), and relief regarding results (21.2%). CONCLUSIONS Social media provided a platform to analyze unprompted feedback from patients. Patients were most concerned with their scoliosis correction surgery in the period of time 2 weeks or more after surgery. Themes that were most commonly found on Instagram posts were offering or seeking online support from other patients and concern about the surgical scar. Patient-controlled social media platforms, like Instagram, may provide a useful mechanism for healthcare providers to understand the patient experience following scoliosis correction surgery. Such platforms may help in evaluating postoperative satisfaction and improving postoperative quality of care.

Background: Occipital condyle fractures (OCFs) have been reported in up to 4–16% of individuals suffering cervical spine trauma. The current management of OCF fractures relies on a rigid cervical collar for 6 weeks or longer. Here, we calculated the rate of acute and delayed surgical intervention (occipitocervical fusion) for patients with isolated OCF who were managed with a cervical collar over a 10-year period at a single institution. Methods: This was a retrospective analysis performed on all patients admitted to a Level 1 Trauma Center between 2008 and 2018 who suffered traumatic isolated OCF managed with an external rigid cervical orthosis. Radiographic imaging was reviewed by several board-certified neuroradiologists. Demographic and clinical data were collected including need for occipitocervical fusion within 12 months after trauma. Results: The incidence of isolated OCF was 4% (60/1536) for those patients admitted with cervical spine fractures. They averaged 49 years of age, and 58% were male falls accounted for the mechanism of injury in 47% of patients. Classification of OCF was most commonly classified in 47% as type I Anderson and Montesano fractures. Of the 60 patients who suffered isolated OCF that was managed with external cervical orthosis, 0% required occipitocervical fusion within 12 months posttrauma. About 90% were discharged, while the remaining 10% sustained traumatic brain/orthopedic injury that limited an accurate neurological assessment. Conclusion: Here, we documented a 4% incidence of isolated OCF in our cervical trauma population, a rate which is comparable to that found in the literature year. Most notably, we documented a 0% incidence for requiring delayed occipital-cervical fusions.

Prospective, multicenter.To determine if stiffness significantly affects function or satisfaction after pan-lumbar arthrodesis.The Lumbar Stiffness Disability Index (LSDI) is a validated measure of the effect of lumbar stiffness on functional activities. Data suggests that patients undergoing fusion of the entire lumbar spine are at greatest risk of functional limitations from stiffness.The LSDI, Short Form 36, Scoliosis Research Society-22, and Oswestry Disability Index were administered preoperatively and at 2-year minimum follow-up to 103 spinal deformity patients from 11 centers. Patients were separated according to the proximal arthrodesis level; upper thoracic (T2-5) to pelvis (UT-Pelvis) or thoraco-lumbar (T10-T12) to pelvis (TL-Pelvis). Outcome scores were compared using Student t test or Tukey-Kramer Honest Significant Difference Analysis of Variance. Regression analysis of final LSDI scores versus Scoliosis Research Society-22 Satisfaction scores was performed.Mean ages, baseline values, and final scores of all outcome parameters were statistically equivalent in the two groups. Final LSDI scores did not change significantly from baseline in the UT-Pelvis (P = 0.478) or TL-Pelvis (P = 0.301) groups. In contrast, highly significant improvements (P ≤ 0.0001) from baseline were seen in both groups for other health-related QoL measures. The 2-year Satisfaction scores were statistically equivalent in the two groups, and the correlation between final LSDI and Satisfaction scores in the entire cohort was not significant (R = 0.013, P = 0.146).Patients undergoing pan-lumbar arthrodesis for adult spinal deformity did not experience substantial increases in disability due to stiffness of the low back, although they did report significant improvements in other health-related QoL measures. Further, LSDI scores did not correlate with patient satisfaction. There were no significant differences in perceived stiffness effects whether arthrodesis stopped in the thoracolumbar or upper thoracic regions. We hope these results will be useful to spine surgeons and patients during preoperative planning and discussions.2.

Background: Craniovertebral junction is a complex anatomical location posing unique challenges to the surgical management of its pathologies. We aimed to identify the fifty most-cited articles that are dedicated to this field. Methods: A keyword search using the Thomson Reuters Web of Knowledge was conducted to identify articles relevant to the field of craniovertebral junction surgery. The articles were reviewed based on title, abstract, and methods, if necessary, and then ranked based on the total number of citations to identify the fifty most-cited articles. Characteristics of the articles were determined and analyzed. Results: The earliest top-cited article was published in 1948. When stratified by decade, 1990s was the most productive with 16 articles. The most-cited article was by Anderson and Dalonzo on a classification of odontoid fractures. By citation rate, the most-cited article was by Herms and Melcher who described Goel's technique of atlantoaxial fixation using C1 lateral mass screws and C2 pedicle screws with rod fixation. Atlantoaxial fixation was the most common topic. The United States, Barrow Neurological Institute, and VH Sonntag were the most represented country, institute, and author, respectively. The significant majority of articles were designed as case series providing level IV evidence. Conclusion: Using citation analysis, we have provided a list of the most-cited articles representing important contributions of various authors from many institutions across the world to the field of craniovertebral junction surgery.

Patients with cervical disc herniation can be asymptomatic or present with radiculopathy or myelopathy symptoms. Generally, they are located anterior or antero-laterally in the epidural space. We present a case of an extruded cervical disc with a dorso-lateral migration, similar to a tumoral extradural lesion. Sequestered cervical disc herniation should be considered in the differential diagnosis of dorso-lateral lesions.

Background Perioperative neurologic complication after an anterior cervical discectomy and fusion (ACDF) is uncommon but may have significant clinical consequences. Objective We aim to estimate the incidence of perioperative neurologic complications, identify their risk factors, and evaluate their impact on morbidity and mortality after ACDF. Methods ACDF cases (n = 317,789 patients) were extracted from the National Inpatient Sample between 1999 and 2011. Based on their Elixhauser-van Walraven score (VWR), patients were classified as low (VWR 14) for surgery. The primary outcome was perioperative neurologic complications. Secondary outcomes included morbidity (hospital length of stay >14 days or discharge disposition to a location other than home) and in-hospital mortality. Results The rate of perioperative neurologic complications, morbidity, and mortality after ACDF was 0.4%, 8.4%, and 0.1%, respectively. Perioperative neurologic complications were highly associated with in-house morbidity (odds ratio [OR], 3.7 [3.1–4.4]) and mortality (OR, 8.0 [4.1–15.5]). The strongest predictors for perioperative neurologic complications were moderate- (OR, 3.1 [2.6–3.7]) and high-risk VWR (OR, 5.4 [3.3–8.9]), postoperative hematoma/seroma formation (OR, 5.4 [3.9–7.4]), and obesity (OR, 1.9 [1.6–2.3]). The rate of perioperative neurologic complications increased from 0.2% to 0.7% from 1999 to 2011, which was temporally associated with the rise in moderate- (P = 0.002) and high-risk patients (P = 0.001) undergoing ACDF. Conclusions Perioperative neurologic complications are independent predictors of in-hospital morbidity and mortality after ACDF. Both morbidity and perioperative neurologic complications have increased between 1999 and 2011, which may be due, in part, to increasing numbers of moderate- and high-risk patients undergoing ACDF.

Iatrogenic spinal cord injury (SCI) is a cause of potentially debilitating post-operative neurologic complications. Currently, intra-operative neurophysiological monitoring (IONM) via somatosensory evoked potentials and motor-evoked potentials is used to detect and prevent impending SCI. However, no empirically validated interventions exist to halt the progression of iatrogenic SCI once it is detected. This is in part due to the lack of a suitable translational model that mimics the circumstances surrounding iatrogenic SCI detected via IONM. Here, we evaluate a model of simulated contusive iatrogenic SCI detected via IONM in adult female Sprague-Dawley rats. We show that transient losses of somatosensory evoked potentials responses are 88.24% sensitive (95% confidence interval [CI] 63.53-98.20) and 80% specific (95% CI 51.91-95.43) for significant functional impairment following simulated iatrogenic SCI. Similarly, we show that transient losses in motor-evoked potentials responses are 70.83% sensitive (95% CI 48.91-87.33) and 100% specific (95% CI 62.91-100.00) for significant functional impairment following simulated iatrogenic SCI. These results indicate that our model is a suitable replica of the circumstances surrounding clinical iatrogenic SCI.

Retrospective analysis.To define thoracic compensation and investigate its association with postoperative reciprocal thoracic kyphosis and proximal junctional kyphosis (PJK) SUMMARY OF BACKGROUND DATA.: Adult spinal deformity (ASD) patients recruit compensatory mechanisms like pelvic retroversion and knee flexion. However, thoracic hypokyphosis is a less recognized compensatory mechanism.Patients enrolled in a multicenter ASD registry undergoing fusions to the pelvis with upper instrumented vertebra (UIV) between T9 and L1 were included. Patients were divided into those with postoperative reciprocal thoracic kyphosis (reciprocal kyphosis [RK]: change in unfused thoracic kyphosis [TK] ≥15°) with and without PJK and those who maintained thoracic alignment (MT). Thoracic compensation was defined as expected thoracic kyphosis (eTK) minus preoperative TK.For RK (n = 117), the mean change in unfused TK was 21.7° versus 6.1° for MT (n = 102) and the mean PJK angle change was 17.6° versus 5.7° for MT (all P 0.001). RK and MT were similar in age, body mass index (BMI), sex, and comorbidities. RK had larger preoperative PI-LL mismatch (30.7 vs. 23.6, P = 0.008) and less preoperative TK (22.3 vs. 30.6, P 0.001), otherwise sagittal vertical axis (SVA), pelvic tilt (PT), and T1 pelvic angle (TPA) were similar. RK patients had more preoperative thoracic compensation (29.9 vs. 20.0, P 0.001), more PI-LL correction (29.8 vs. 17.3, P 0.001), and higher rates of PJK (66% vs. 19%, P 0.001). There were no differences in preoperative health-related quality of life (HRQOL) except reciprocal kyphosis (RK) had worse Scoliosis Research Society questionnaire (SRS) appearance (2.2 vs. 2.5, P = 0.005). Using a logistic regression model, the only predictor for postoperative reciprocal thoracic kyphosis was more preoperative thoracic compensation. Postoperatively the RK and MT groups were well aligned. Both younger and older (65 yr) RK patients had greater thoracic compensation than MT counterparts. The eTK was not significantly different from the postoperative TK for the RK group without PJK (P = 0.566).The presence of thoracic compensation in adult spinal deformity is the primary determinant of postoperative reciprocal thoracic kyphosis and these patients have higher rates of proximal junctional kyphosis.3.

In the United States, the number of posterior cervical fusions has increased substantially. Perioperative neurologic complications associated with this procedure, such as spinal cord and peripheral nerve injuries, can have significant effects on patient health. We examined the impact of perioperative neurologic deficits on mortality in patients undergoing posterior cervical fusion. The secondary aim was to understand the risk factors for perioperative neurologic complications.Data were collected from the National Inpatient Sample (NIS) Health Cost Utilization Project (HCUP) between 1999 and 2011. Patients younger than 18 years and older than 80 years were excluded, as were patients who underwent posterior cervical fusion caused by trauma. Patient demographics and comorbidities were compiled as well as variables that have been associated with increased risk of perioperative neurologic deficits. We used the van Walraven score, a weighted numeric surrogate for the Elixhauser comorbidity index, as a covariate to assess comorbidities that have been associated with in-hospital mortality and morbidity after posterior cervical fusion. In addition, we performed univariate comparisons between covariates and surgical outcomes. We conducted a multivariable logistic regression, adjusting for many of the covariates, as well as trend analyses.An analysis of 33,644 patients yielded an overall rate of perioperative neurologic deficits, morbidity, and mortality of 1.08%, 40.44%, and 1.00%, respectively. Perioperative neurologic deficits were independent risk factors predictors of in-hospital mortality (odds ratio, 5.270; P0.0001) and morbidity (odds ratio, 2.579; P0.0001). Other statistically significant predictors of mortality included increasing van Walraven score, myocardial infarction, metastatic cancer, and weight loss. These were also independent predictors of morbidity along with but not limited to age, device complications, congestive heart failure, paralysis, diabetes with chronic complications, deficiency anemias, device complications, and intraspinal abscess.Perioperative neurologic deficits are serious complications of posterior cervical fusion and can independently predict in-hospital mortality and morbidity. As this procedure continues to be used increasingly, attention should be directed toward preventing these complications and intervening earlier in patients who have a neurologic deficit. Future efforts should be geared toward screening for at-risk patients with the initiation of surgical prehabilitation.

This chapter summarizes a few of the major themes that arise from their work, provides some answers to the "Big Questions" about the future directions of intergovernmental relations (IGR) and intergovernmental management, and identifies areas for further research. The growth in the number of federal grant-in-aid programs, discretionary spending, regulatory federalism, and unfunded mandates have underscored that the intergovernmental power "tilt" has been in the direction of Washington, DC for many years. The intergovernmental pendulum might swing more in the direction of the states if the federal government's fiscal position becomes unsustainable or if the Trump administration and Congress succeed in "deconstructing the administrative state." Several contributors have noted that the deinstitutionalization of intergovernmental organizations has created a void in the understanding of IGR and in appreciation of the views of the partners in the federal system on policies and programs that transcend governmental and sectoral boundaries.

A retrospective review.This study aimed to determine the factors associated with malpractice litigation in cases involving spine surgery in the United States.Medical malpractice is of substantial interest to the medical community due to concerns of increased health care costs and medical decision-making for the sole purpose of reducing legal liability.The Westlaw online legal database (Thomson Reuters, New York, NY) was searched for verdict and settlement reports pertaining to spine surgery from 2010 to 2015. Data were collected regarding type of procedure, patient age and gender, defendant specialty, outcome, award, alleged cause of malpractice, and factors involved in the plaintiff's decision to file. Initial search queried 187 cases, after which exclusion criteria were applied to eliminate duplicates and cases unrelated to spine surgery, yielding a total of 98 cases for analysis.The verdict was in favor of the defendant in 62 cases (63.3%). Neurosurgeons and orthopedic surgeons were the most common defendants in 29 (17.3%) and 40 (23.8%) of the cases, respectively. A perceived lack of informed consent was noted as a factor in 24 (24.4%) of the cases. A failure to diagnose or a failure to treat was noted in 31 (31.6%) and 32 (32.7%) cases, respectively. Median payments for plaintiff verdicts were nearly double those of settlements ($2,525,000 vs. $1,300,000). A greater incidence of plaintiff verdicts was noted in cases in which a failure to treat (P 0.05) was cited, a patient death occurred (P 0.05), or an emergent surgery had been performed (P 0.01).Overall, physicians were not found liable in the majority of spine surgery malpractice cases queried.4.

Proximal junctional failure (PJF) should be distinguished from proximal junctional kyphosis, which is a recurrent deformity with limited clinical impact. PJF includes mechanical failure, and is a significant complication following adult spinal deformity surgery with potential for neurologic injury and increased need for surgical revision. Risk factors for PJF include age, severity of sagittal plane deformity, and extent of operative sagittal plane realignment. Techniques for avoiding PJF will likely require refinements in both perioperative and surgical strategies.

Background Context Perioperative neurologic complications after spine surgery may increase morbidity and health-care costs related to the procedure. Purpose We estimate the national incidence of perioperative neurologic complications following anterior cervical discectomy and fusion (ACDF), posterior cervical fusion, and thoracolumbar fusion procedures using the Nationwide Inpatient Sample (NIS) data from 1999 to 2011. Additionally, we identify risk factors for developing perioperative neurologic complications and the effects of these injuries on quantifiable patient outcomes. Study Design A cross-sectional study was carried out. Patient Sample All patients included in the NIS databases from 1999 to 2011 comprised the sample. Outcome Measures The primary outcome evaluated was the incidence of new neurologic deficits following elective spine surgery. Secondary outcomes evaluated include length of hospital stay, total hospital charges, hospital mortality rate, and discharge disposition. Methods A retrospective analysis of the NIS databases from the years 1999 to 2011 was conducted to identify the proportion of patients who underwent ACDFs, posterior cervical fusions, and thoracolumbar fusions who also developed perioperative neurologic complications. Statistical analyses were also conducted to identify statistically significant differences in demographics and outcomes between patients who did and did not develop perioperative neurologic complications. Results From 1999 to 2011, the total national incidence of perioperative neurologic deficits following elective ACDFs, posterior cervical fusions, and thoracolumbar fusions was 0.82%, which equates to a total of 15,066 patients who experienced these complications. The annual incidence rate of perioperative neurologic deficits has increased 54.41%, from 0.68% in the year 1999 to 1.05% in the year 2011. Additionally, the total number of procedures performed increased from 82,167 in 1999 to 186,353 in the year 2011. Perioperative neurologic deficits were associated with longer lengths of stay (9.68 days vs. 2.59 days; p Conclusions The incidence rate of perioperative neurologic deficits associated with elective spine surgery documented in the NIS has increased over the time period from 1999 to 2011. The number of elective spine procedures performed has also increased over the same time period. Finally, outcomes data indicate that occurrence of perioperative neurologic complications is associated with increased rates of morbidity and mortality, as well as increased health-care use and cost. These trends indicate that the perioperative neurologic complications following spine surgery represent a growing problem in today's health-care system; further study is warranted to prevent and treat these complications to improve patient care and reduce health-care use and cost.

STUDY DESIGN This is a multicenter retrospective review of prospectively collected cases. OBJECTIVE Our objective was to evaluate the relationship between patient satisfaction, health-related quality of life (HRQoL) scores, complications, and radiographic measures at 2 years postoperative follow-up. SUMMARY OF BACKGROUND DATA For patients receiving operative management for adult spine deformity (ASD), the relationship between HRQoL measures, radiographic parameters, postoperative complications, and self-reported satisfaction remains unclear. METHODS Data from 248 patients across 11 centers within the United States who underwent thoracolumbar fusion for ASD and had a minimum of 2 years follow-up was collected. Pre- and postoperative scores were obtained from the Scoliosis Research Society 22-item (SRS-22r), the Oswestry Disability Index (ODI), the 36-Item Short Form Health Survey (SF-36), and the Visual Analogue Scale. Sagittal vertical axis, coronal C7 plumbline, lumbar lordosis, pelvic tilt, T1 pelvic angle, and the difference between pelvic incidence and lumbar lordosis were assessed using postoperative radiographic films. Satisfaction (SAT) was assessed using the SRS-22r; patients were categorized as highly satisfied (HS) or less satisfied (LS). The correlation between SAT and HRQoL scores, radiographic parameters, and complications was determined. RESULTS When compared with LS (n = 60) patients, HS (n = 188) patients demonstrated greater improvement in final ODI, SF-36 component scores, SRS-Total, and Visual Analogue Scale back scores (P

Background: Intracranial pressure (ICP) monitoring is not routinely used during complex spinal deformity correction surgery. The authors report a 66-year-old male who during thoracolumbar deformity surgery required the placement of an ICP monitor due to the underlying history of a superior vena cava syndrome (e.g., s/p right jugular stent). Case Description: A 66-year-old male with multiple prior lumbar spinal procedures presented with lower back and bilateral lower extremity pain, paresthesias, and weakness. He had a history of chronic left internal jugular and brachiocephalic venous occlusion (e.g., he had a right internal jugular stent). During deformity surgery, a frontal intraparenchymal ICP monitor was placed. During the early portion of the operation, bed adjustments (increasing reverse trendelenburg position) were required to compensate for ICP elevations as high as 30 mm Hg. A subsequent inadvertent durotomy during decompression lowered the ICP to

Background Nonvascularized autologous grafts used for sellar reconstruction in transseptal transsphenoidal surgery are commonly applied in the setting of intraoperative cerebrospinal fluid (CSF) leak and have been shown to be effective in preventing postoperative complications. Objective To assess the clinical implications of intraoperative CSF leak, to evaluate the efficacy of repair techniques using autologous nonvascularized materials, and to analyze the nature and timing of failures. These data may serve as a basis for assessing the utility of innovations in techniques and implant technologies. Methods A review was conducted of 257 consecutive patients who underwent transsphenoidal surgery that was complicated by intraoperative CSF leak from 1995 to 2001. Sellar reconstruction was performed with autologous materials except in reoperations in which septal materials were not available; lumbar drain catheters were used selectively. Results Six of the 257 patients (2.3%) developed postoperative CSF rhinorrhea occurring an average of 6.6 days after surgery. All 6 underwent reoperation, with 5 of 6 managed with operative lumbar drainage. Bacterial meningitis developed in 3 of 257 (1.2%). Worsening in visual function occurred in 8 of 257 (3.1%), with 1 of 257 (0.3%) suffering from permanent worsening of visual function. Additional surgery was performed in 2 of these patients, resulting in successful reversal of visual loss. Ten of 257 patients (3.9%) developed a subcutaneous hematoma at the fat graft harvest site, with 1 patient requiring surgical re-exploration. Conclusions Watertight closure of the sella with autologous materials is effective in preventing postoperative rhinorrhea. Complications specific to the technique include graft site hematoma (4%) and rare instances of visual loss caused by optic nerve compression.

How opportunity is distributed among its component racial groups in a metropolitan region is an important question and is likely to become more so as regions become denser economically and socially. The extent to which governmental structure contributes to racial sorting has been debated since the development of public choice theory. To evaluate how various structural, political, and historical factors affect the relative distribution of opportunity between racial groups in urban regions of the United States, the authors apply a cross-sectional approach, comparing regional characteristics at the time of the 2000 census. Their analysis of the correlates and determinants of racial disparities suggests that these factors collectively explain significant amounts of regional variation with respect to residential racial segregation, cost and quality of housing, and income. The number of local governments and fiscal power diffusion explain some racial disparity. Larger size of black population in a region is associated with less segregation, but more economic disparity while the opposite tends to be true for Hispanics.More liberal state policies and political culture occur where metropolitan black-white segregation is higher. Higher central city incomes appear to decrease segregation while higher suburban income increases it.

A series of court cases banned patronage except for leadership and confidential positions. In Cook County and Chicago, the Shakman Decree required the establishment of an antipatronage staffing system to ensure that political considerations did not enter into staffing decisions. Despite the court prohibitions and the antipatronage staffing systems, patronage continued to flourish. A number of unethical and illegal violations included falsifying exam scores and interviews, demanding political contributions for jobs and contracts, and covering up wrongdoing. These patronage abuses led to successful criminal prosecution of a number of individuals. Political influence had a corrupting effect on the government bureaucracy. At a time when many public personnel systems are moving toward at-will employment systems to provide flexibility and responsiveness to the political leaders, this direction might not be in the public’s best interest.

This study examined the salivary testosterone (T) and cortisol (C) responses of elite women hockey players across 4 activities (light and heavy training, club and International competitions). The players formed an oral contraceptive (OC) group (n=10) and a Non-OC (n=19) group for analysis. The Non-OC group had higher T levels (by 31-52%) across all activities, whilst the OC group showed signs of reduced T and C reactivity when data were pooled. As a squad, positive T and C changes occurred with heavy training (45%, 46%), club competitions (62%, 80%) and International competitions (40%, 27%), respectively. Our results confirm that OC use lowers T levels in women athletes whilst reducing the T and C responses to training and competition activities within the sporting environment. Differences in the physical and/or psychological demands of the sporting activity could be contributing factors to the observed hormone responses. These factors require consideration when applying theoretical models in sport, with broader implications for women around exercising behaviours and stress physiology.

This study examined the effects of Sprint Interval Cycling (SIT) on muscle oxygenation kinetics and performance during the 30-15 intermittent fitness test (IFT). Twenty-five women hockey players of Olympic standard were randomly selected into an experimental group (EXP) and a control group (CON). The EXP group performed six additional SIT sessions over six weeks in addition to their normal training program. To explore the potential training-induced change, EXP subjects additionally completed 5 x 30s maximal intensity cycle testing before and after training. During these tests near-infrared spectroscopy (NIRS) measured parameters; oxyhaemoglobin + oxymyoglobin (HbO2+ MbO2), tissue deoxyhaemoglobin + deoxymyoglobin (HHb+HMb), total tissue haemoglobin (tHb) and tissue oxygenation (TSI %) were taken. In the EXP group (5.34 ± 0.14 to 5.50 ± 0.14 m.s(-1)) but not the CON group (pre = 5.37 ± 0.27 to 5.39 ± 0.30 m.s(-1)) significant changes were seen in the 30-15 IFT performance. EXP group also displayed significant post-training increases during the sprint cycling: ΔTSI (-7.59 ± 0.91 to -12.16 ± 2.70%); ΔHHb+HMb (35.68 ± 6.67 to 69.44 ± 26.48 μM.cm); and ΔHbO2+ MbO2 (-74.29 ± 13.82 to -109.36 ± 22.61 μM.cm). No significant differences were seen in ΔtHb (-45.81 ± 15.23 to -42.93 ± 16.24). NIRS is able to detect positive peripheral muscle oxygenation changes when used during a SIT protocol which has been shown to be an effective training modality within elite athletes.

A metropolitan region does not have formal institutional structures such as nations, states, and cities, but it is a system that can be conceptualized and studied as a whole. The study of metropolitan areas too often ignores the dynamic relationship sat the intersection of state and local governments. This study suggests a two-dimensional typology of governance in metropolitan regions. The authors found that governance affects the long-term competitiveness of the metropolitan economy. Governance does not determine economic outcomes but reduces the ability to adapt. The worst combination for metropolitan competitiveness is decentralization within regions where there is a centralized state government.

The author relates tenets of urban regime theory to the major elements of new regionalism. He develops a framework of government and private sector structures and factors that facilitate the development of regional governing regimes. He categorizes these structures and elements as high, medium, or low according to the extent to which they facilitate or hinder the development of regional regimes. This framework is used in an analysis of new regionalism in the Pittsburgh and Chicago regions. The author concludes that the Pittsburgh region's private sector regime development capacity is in the high category while its government capacity is in the medium category. The Chicago region's private sector regime development capacity is placed in the medium category while its government sector capacity is judged to be in the low category.

The extent of centralized or decentralized government has been an issue in America’s governing system since the Revolutionary War. The major issues debated at the Constitutional Convention revolved around the amount of authority the national government should possess in relation to the states. The centralization-decentralization issue is still a matter of contention, but a major focus of the debate has shifted to the metropolitan area. Despite the differences in time and levels of governments, many of the same arguments made during the constitutional debates are similar to the arguments made for and against government reform in metropolitan areas today. The author reconsiders the centralizationdecentralization issues debated at the Constitutional Convention and the ratification fight in the context of the current debate in metropolitan areas. Theoretical support for this exercise is provided by the international relations model. An application of the issues debated and resolved by the colonists to the current debate on the extent of centralized government in metropolitan areas would favor the establishment of metropolitan government. In 1787 a group met in Philadelphia to improve the Articles of Confederation. Although the group was divided in how to improve the Articles, there was general agreement that the central government needed to have more authority to govern the nation. The major issue to be resolved, which overshadowed all other issues, was the authority relationships between the states and the central government. While many wanted simply to strengthen the Articles, there were a few who felt the Articles allowed too much decentralization, and they wanted to establish an entirely new framework with much more central authority. The intensity of the struggle over the centralization-decentralization issue was evident from the debates at the Constitutional Convention and the fight over the ratification. The colonial nationalists were successful in establishing a government system with more centralized authority at the national level. This was accomplished despite bitter opposition from those who supported a more decentralized system of government. The ratification did not resolve the issue of authority relationships between the states and the national government but, with the exception of the Civil War, shifted it to the courts and the political process within the framework established in the Constitution. The centralization-decentralization issue has also filtered down to the nation’s urban areas. Although the level of government and the time period are different, a number of similar issues that plagued relationships among the states in colonial times are also evident among local governments in urban areas. Advocates of a more centralized governing system in metropolitan regions, as in the colonial era, are working to change the status quo or to reform the current local government system. In this essay, I review the literature on the issue of the amount of authority to give to the central government in the establishment of the Constitution. I review the subsequent results of a stronger central government relative to the arguments presented for and against a more centralized authority. Finally, I compare that

Regime theory has been used extensively in community governance studies. An analysis of the urban regime theory literature and the regional governance literature reveals that urban regime theory can also be useful in the study of regional governance. Both literatures indicate the critical importance of the nongovernmental sector for effective governance. Indeed, because of the usually weak regional political constituency, the private sector often takes the lead in regional governance initiatives. However, private sector efforts are only successful to the extent that coalitions can be developed with political leaders. The author conducted a study of regionalism in the Chicago metropolitan area where leaders from both sectors have recently formed organizations to address regional issues. He analyzed the two organizations and whether a regional regime can develop given the region’s political culture of local government autonomy and the history of antagonism between the central city and the suburbs.

As a result of court cases, Illinois state government and a number of local governments in Cook County have established nonpatronage staffing systems. An analysis of the impact of these staffing systems reveals that patronage has not been eliminated. It is still alive and well but has changed in significant ways. Although there have been positive impacts on staffing from nonpatronage systems, they tend to be overly centralized and bureaucratic. This causes time delays in filling vacant positions and requires additional time and paperwork on the part of hiring officials. Nonpatronage systems are not designed to attract the best and the brightest but rather to keep patronage-oriented applicants out. The author recommends that staffing systems be designed around a public service orientation to strike a balance between patronage and merit. Staffing such systems will de-emphasize centralized, bureaucratic antipatronage procedures in favor of more flexibility and accountability in the operating departments.