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To identify characteristics associated with higher incidence of intraoperative deterioration of neurophysiological potentials related to spinal tracts in cervical spine surgeries.Electrophysiological raw data and neurophysiological case reports of 1,611 patients from multiple medical centers, who underwent cervical spine surgery for decompression and/or fusion, were retrospectively reviewed. Patient-related and procedure-related variables were identified and analyzed for correlation with intraoperative neurophysiological event of the spinal tracts. The neurophysiological events were analyzed for identification of collective characteristics.The study cohort presented consistent dominancy of male over female patients (67% vs. 33%). Intraoperative deterioration of spinal tract-derived potentials was noted in 10.5% of the total cases, which was not correlated with gender, age, or indication of the surgery. Higher incidence of neurophysiological events was noted in patients with impaired baseline of motor evoked potentials from the thenar muscle (P = 0.01) or somatosensory evoked potentials of the posterior tibial nerve (P = 0.0002). Procedures of circumferential approach or procedures that involved ≥3 spinal levels demonstrated higher incidence of neurophysiological events as well (P = 0.0003 and 0.001, respectively).Patients with deteriorated neurophysiological baseline and procedures of extensive intervention are at higher risk of intraoperative neurophysiological event in cervical spine surgery. Inclusion of intraoperative neurophysiological monitoring should be encouraged in complicated cases of cervical spine surgeries.

Study design This is a prospective observational study. Objective The aim of this study is to determine the rate of occult infection after instrumented spine surgery in presumed aseptic patients. Summary of background data The reported incidence rate of delayed/occult infection determined by positive culture swabs after instrumented spine surgery in prospective studies is 0.2%-6.9%. However, this rate may be higher as delayed infections are challenging to diagnose. Fever can be absent and inflammatory markers are often normal. If indolent organisms exist in low concentrations surrounding the instrumentation, these organisms can possibly avoid detection and disrupt bone formation leading to instrumentation loosening, pain generation, and/or failure of a solid fusion. Materials and methods This study included 50 consecutive presumed aseptic patients undergoing a posterior revision requiring removal of instrumentation at least 6 months following their index procedure. Common markers of infection were examined preoperatively. Multiple culture swabs were taken directly from the removed instrumentation and cultured for 14 days. Results Of the 50 patients, 19 (38%) were culture-positive (CP) for bacteria upon removal of their instrumentation, with 14 patients (28%) having ≥2 positive specimens of the same organism. The average length of time between the index procedure and the revision surgery was 4.55 years (range: 0.53-21 y). Polymicrobial infections were found in 26% (5/19) of CP patients. The most prevalent microorganism found was Propionibacterium acnes, in 63% (12/19) of CP patients. There was no significant difference between CP and culture-negative patients regarding preoperative markers for infection, age, or length between index and revision procedures. Conclusions The results of this study indicate a positive culture rate of 38% in presumed aseptic patients who had previously undergone instrumented spine surgery. These results are consistent with other retrospective studies and are >6 times greater than any previous prospective study utilizing culture swabs. Level of evidence Level-III.

Study design Retrospective cohort study with a cross-sectional comparison. Objectives To assess sexual function and experience in adult women who had scoliotic correction for adolescent idiopathic scoliosis (AIS). Methods Women ages 18–40 years with a history of scoliosis, who were braced or underwent uncomplicated posterior scoliosis correction for AIS, followed for two years or more since treatment were included. Sexual function was assessed using the Female Sexual Distress Scale-Revised (FSDS-R) and the Female Sexual Function Index (FSFI) questionnaires. Participants’ scores were compared to those of a control group consisting of age-matched healthy women. Results Of 115 women who responded to the questionnaires, 40 (35%) had surgical treatment (mean age 25.1; range 19–35 years; mean time since surgery 8.2 years; range 3–12 years) and 35 (30%) were braced (mean age 23.3; range 18–27 years; mean time since treatment 3.6 years; range 3–5 years). The control group consisted of a cohort of 40 (35%) aged-matched healthy women. According to the FSDS-R, significantly more women with scoliotic correction for AIS reported sexual distress compared to healthy controls (25% vs 12%, respectively), and the difference in the total mean scores (7.05 vs 5.34, respectively), was significant (P < .001). Additionally, the mean overall FSFI score for scoliotic-corrected women was 24.2 (range 17.5–29.1) within the pathological range (Conclusions High rates of sexual distress and dysfunction were reported in women with a history of AIS, thus, there appears to be long-term consequences years after deformity correction by brace or surgical correction.

Unstable fractures in sick or elderly patients are on the rise. These patients who are at high risk for surgery present a challenge for surgeons and anesthesiologists. In patients with American Society of Anesthesiologists (ASA) scores 3 to 4, the risk is even higher because of the high rate of intraoperative complications.All patients with ASA scores 3 to 4 who presented with unstable fractures of the spine to a level-one trauma center were assessed, and they underwent awake spinal percutaneous fixation, with mild sedation and local anesthesia. Demographics, radiology, and the outcome were collected.Nineteen patients were operated between the years 2019 and 2021. Average follow-up was 12 months (range 8 to 24 months); six patients were female and 13 males. The average age was 77.7 years; the ASA score was 3 to 4 in all patients. There were 10 extension-type injuries, six unstable burst injuries, two chance fractures, and one teardrop fracture. All patients underwent unilateral fixation, and just one patient underwent bilateral fixation; cement augmentation was done in 16 of the patients. No neurologic complication was observed. One case of infection presented 4 months after surgery. All patients were discharged ambulating.Awake fixation in extreme cases is safe and feasible; a dedicated team including an anesthesiologist and radiologist is needed to treat these cases safely and quickly.

Background Spinal trauma patients treated in a specialized hybrid operating room (OR) using two robotic systems communicating during surgery. Methods Retrospective review of patients with thoracolumbar or sacral fractures who underwent surgical fixation between Jan 2017 to Jan 2020 with robotic-guided percutaneous pedicle screw insertion in the specialized hybrid OR with Robotic flat panel 3D C-arm (ArtisZeego) for intraoperative interventional imaging connected with the robotic-guidance platform Renaissance (Mazor Robotics). Results Twenty eight surgeries were performed in 27 patients; 23 with traumatic spinal fractures, 4 with multi-level thoracolumbar compression fractures due to severe osteoporosis. Average patient age 49 (range 12–86). Average radiation exposure time 40 s (range 12–114 s). Average radiation exposure dose 11,584 ± SD uGym2 (range 4454–58,959). Lumber levels operated on were between T5 and S2 (shortest three vertebras and longest eight vertebras). 235 (range 5–11) trajectories were performed. All trajectories were accurate in all cases percutaneous pedicle screws placement was correct, without breach noted at the pedicle in any of the cases. No major complications reported. In all cases, follow-up X-rays showed adequate fracture reduction with restoration. Conclusions Merging of surgical robotics technologies increases patient safety and surgeon and patient confidence in percutaneous spine traumatic procedures.

Background and Context Metastatic epidural spinal cord compression (MESCC) is a disabling consequence of disease progression. Surgery can restore or preserve physical function, improving access to treatments that increase duration of survival; however, advanced patient age may deter oncologists and surgeons from considering surgical management. Purpose Evaluate the duration of ambulation and survival in elderly patients following surgical decompression of MESCC. Study Design/Setting Retrospective file review of a prospective database, under institutional review board (IRB) waiver of informed consent, of consecutive patients treated in an academic tertiary care medical center from August 2008 to March 2015. Patient Sample Patients ≥65 years presenting neurological and/or radiological signs of cord compression because of metastatic disease, who underwent surgical decompression. Outcome Measures Duration of ambulation and survival. Methods Patients underwent urgent multidisciplinary evaluation and surgery. Ambulation and survival were compared with age, pre-, and postoperative neurological (American Spinal Injury Association [ASIA] Impairment Scale [AIS]) and performance status (Karnofsky Performance Status [KPS]), and Tokuhashi Score using Kruskal-Wallis and Wilcoxon signed rank tests, Pearson correlation coefficient, Cox regression model, log-rank analysis, and Kaplan-Meier analysis. Results Forty patients were included (21 male, 54%; mean age 74 years, range 65–87). Surgery was performed a mean 3.8 days after onset of motor symptoms. Mean duration of ambulation and survival were 474 (range 0–1662) and 525 days (range 11–1662), respectively; 53% of patients (21 of 40) survived and 43% (17 of 40) retained ambulation for ≥1 year. There was no significant relationship between survival and ambulation for patients aged 65–69, 70–79, or 80–89 years, although Kaplan-Meier analysis suggested stratification. There was a significant relationship between duration of ambulation and pre- and postoperative AIS (p=.0342, p=.0358, respectively) and postoperative KPS (p=.0221). Tokuhashi score was not significantly related to duration of survival or ambulation, and greatly underestimated life expectancy in 22 of 37 (59%) patients with scores 0–11. Conclusions Decompressive surgery led to marked improvement in neurological function and performance status. More than 50% of patients survived for >1 year, some for 3 years or more after surgery.

Study Design: Systematic review. Objectives: Allogeneic blood transfusion-related immunomodulation may relatively suppress the immune system, heightening the risk of infection following spine surgery. This systematic review seeks to determine whether allogeneic blood transfusion increases the risk of postoperative infection and whether there are any factors that modify this association. Methods: PubMed, Cochrane Central Register of Controlled Trials, and reference lists from included studies were searched from inception to April 20, 2017 to identify studies examining the risk of infection following allogeneic blood transfusion in adult patients receiving surgery for degenerative spine disease. Results: Eleven retrospective cohort or case-control studies, involving 8428 transfusion patients and 43 242 nontransfusion patients, were identified as meeting the inclusion criteria. Regarding surgical site infection (SSI), the results were mixed with roughly half reporting a significant association. There was an association between allogeneic transfusion and urinary tract infection (UTI) and any infection, but not respiratory tract infection. There was no statistical modifying effect of lumbar versus thoracic surgery on the association of allogeneic transfusion and SSI, though subgroup analyses in 3 of 4 studies reported a statistical association between transfusion and postoperative infections, including SSI, UTI, and any infection within the lumbar spine. Conclusions: This systematic review failed to find a consistent association between allogeneic transfusion and postoperative infection in spine surgery patients. However, these studies were all retrospective with a high or moderately high risk of bias. To properly examine this association an observational prospective study of sufficient power, estimated as 2400 patients, is required.

We assessed the clinical value of repeat spine CT scan in 108 patients aged 18-60 years who underwent repeat lumbar spine CT scan for low back pain or radiculopathy from January 2008 to December 2010. Patients with a neoplasm or symptoms suggesting underlying disease were excluded from the study. Clinical data was retrospectively reviewed. Index examinations and repeat CT scan performed at a mean of 24.3 ± 11.3 months later were compared by a senior musculoskeletal radiologist. Disc abnormalities (herniation, sequestration, bulge), spinal stenosis, disc space narrowing, and bony changes (osteophytes, fractures, other changes) were documented. Indications for CT scan were low back pain (60 patients, 55%), radiculopathy (46 patients, 43%), or nonspecific back pain (two patients, 2%). A total of 292 spine pathologies were identified in 98 patients (90.7%); in 10 patients (9.3%) no spine pathology was seen on index or repeat CT scan. At repeat CT scan, 269/292 pathologies were unchanged (92.1%); 10/292 improved (3.4%), 8/292 worsened (2.8%, disc herniation or spinal stenosis), and five new pathologies were identified. No substantial therapeutic change was required in patients with worsened or new pathology. Added diagnostic value from repeat CT scan performed within 2-3 years was rare in patients suffering chronic or recurrent low back pain or radiculopathy, suggesting that repeat CT scan should be considered only in patients with progressive neurologic deficits, new neurologic complaints, or signs implying serious underlying conditions.

Study Design Retrospective cohort study with a cross-sectional comparison. Objective To compare the rates of anesthesia prescription and satisfaction with surgery, prevalence and severity of low back pain, prevalence of depression, and sexual dysfunction among pregnant and nonpregnant patients with AIS undergoing correction surgery with pedicle-based systems and healthy woman with a history of pregnancy. Methods Women between the ages of 18 and 40 years who underwent correction surgery for AIS with a pedicle screw system were interviewed regarding pregnancies, child delivery, method of pain control during delivery, and any long-term outcome after delivery. In addition, sexual dysfunction (Female Sexual Distress Scale–Revised [FSDS]), depression (the Beck Depression Assessment Questionnaire), and Scoliosis Research Society 24 (SRS24) questionnaires were administered. Data was compared between patients with AIS without a history of pregnancy and healthy controls. Results Satisfaction with surgery in the AIS pregnant group using the SRS24 questionnaire scored 3.76/5 ( p = 0.0047 when compared with nonpregnant AIS group). Six of the 17 of the women with AIS had severe back pain during pregnancy (35%) mandating home treatment or hospitalization. Of the 17 women, 13 complained of a sustained back pain after child delivery (76%) that impacted their life. In the nonscoliosis group, no back pain attributed to pregnancy was reported. The rates of regional anesthesia prescription among pregnant patients with AIS who underwent correction surgery was 30% (5/17), whereas among healthy pregnant women, rates were 100% (6/6). The SRS24 scores in the patients with AIS were 72% (88/120), showing a low score of 3.69/5 in the pain domains ( p = 0.0048 when compared with nonpregnant patients with AIS). Depression rates were in the normal range and similar in all groups. FSDS scores, used to assess sexual dysfunction, were 4.02 in the pregnancy group and 5.67 in the nonpregnant group (not significant) and 4.6 in the nonscoliosis control group (not significant). Conclusion Women who underwent scoliosis correction suffered from long-term back pain after pregnancy and had decreased satisfaction with surgery. In addition, anesthesiologists refused epidurals in a large number of these patients. A larger study is needed on the topic.

Background During their final year of medical school, Israeli students must consider which specialty to choose for residency. Based on the vocational counseling literature we presumed that choices are made by selecting from a cluster of related specialties while considering professional and socio-economic issues. Methods Questionnaires distributed to final-year medical students at two Israeli medical schools ascertained inclinations toward various medical specialties and the importance of various selection criteria. Analysis focused on seven specialties where >20% of students reported they had positive inclinations. For each such specialty, the specialty and selection criteria query were compared using unpaired two-tailed Student’s t-tests to determine differences between students with positive inclinations toward the specialty with those not so inclined. These data were placed in tables, with the significant differences highlighted to facilitate visual recognition of cluster patterns. Results Completed questionnaires were obtained from 317 of 455 students. Students often had positive inclinations toward more than one specialty (specialty clusters) associated with a group of selection criteria (selection criteria clusters). For example, interest in internal medicine was clustered with interest in internal medicine subspecialties, cardiology and research. Furthermore, there was a “reciprocal” aspect to some specialty cluster patterns. For example, those interested in internal medicine had little interest in surgical specialties. Selection criteria clusters revealed occupational interests and socio-environmental factors associated with the specialty clusters. For example, family medicine, which clustered with pediatrics and psychiatry, had a sub-cluster of: Bedside specialty with family orientation affording long-term patient care. Another sub-cluster was time for childrearing and family, only daytime work and outpatient care. Clusters also revealed students’ perceptions that differed from expected: Cardiology is changing from a cognitive to a procedure-oriented subspecialty, clustering not only with internal medicine and its subspecialties but also with emergency medicine, surgical subspecialties and anesthesiology. Conclusions The concept that career choice involves selecting from a cluster of related specialties provides information about the specialties students might be considering. Moreover, students are not only looking for individual aspects of a specialty, but for a package including clusters of socio-economic and occupational features. Practically, examining clusters can help in career counseling of medical students and assist residency program directors in marketing their specialties. Electronic supplementary material The online version of this article (doi:10.1186/s12909-017-0854-y) contains supplementary material, which is available to authorized users.

Background and Purpose: Painful vertebral compression fractures in cancer patients reduce quality of life and may limit survival. We assessed pain relief, vertebral height restoration, and kyphosis correction following vertebral augmentation using a novel expandable titanium stent implant in cancer patients with painful vertebral compression fractures. Materials and Methods: Patients .18 years of age with metastatic disease who presented symptomatic compression fractures of vertebral bodies T5–L5, with or without a history of osteoporosis, were included in the study. Back pain at presentation, immediately after vertebral stenting, and at 1-, 3-, 6-, and 12-month follow-up was estimated using the visual analog scale (VAS). Vertebral height and local kyphotic angle (alpha angle) were measured on lateral standing X-ray before and 1–3 months after stenting. Results: Forty-one cancer patients with painful vertebral compression fractures underwent vertebral stenting procedures at 55 levels. There was no perioperative mortality and no significant complication. Median preoperative VAS was 8.0 (range 8–10), falling to 2.0 immediately postop (range 1–6, P 5 0.000) and 0 at all subsequent follow-up (P # 0.012). Mean preoperative vertical height loss was 25.8% (range 0– 84.0%) versus a postoperative mean of 18.0% (range 0–66.0%, P 5 0.000). Median pre- and postoperative kyphotic angle improved from 8.3u (range 0.2u–54.0u) to 7.1u (range 0.2u–25.0u, P 5 0.000). Wilcoxon signed rank test or student’s t-test was used for comparisons. Conclusions: Vertebral augmentation using a novel vertebral stenting system provided immediate and enduring pain relief and improved vertebral height loss and kyphotic angle.

Distal tibial fractures tend towards delayed- or nonunion. The purpose of this study was to evaluate the safety and efficacy of early minimally invasive intervention (MII) in the treatment of these fractures. A total 24 consecutive patients who underwent operative treatment for distal tibial fractures were randomized into a control and an intervention group. MII entailed aspirating iliac crest bone marrow and peripheral blood, yielding mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP) respectively, that were mixed with demineralized bone matrix (DBM) and injected under fluoroscopic control into the fracture site. No complications occurred in either group. The median time to union was 1.5 months in the MII group and 3 months in the control group. MII was found to be a safe and efficient procedure.

Study design: Systematic review. Study rationale: Disc degeneration is a common process starting early in life. Often disc herniation is an early step in disc degeneration, which may cause pain or stenosis. How quickly this subsequent disc degeneration occurs following a disc herniation and subsequent surgical treatment and whether certain spinal procedures increase the rate of degeneration remain unclear. Objectives: To investigate the risk of subsequent radiographic disc degeneration following discectomy, discography, and conservative care in patients with a first-time diagnosed herniated nucleus pulpous (HNP) and to ascertain whether this risk in these defined groups changes over time. Methods: A systematic review of pertinent articles published up to June 2012. Key articles were searched to identify studies evaluating the risk of subsequent radiographic disc degeneration following treatment for HNP. Studies that included patients undergoing secondary surgery for disc herniation or that did not use a validated classification system to measure the severity of disc degeneration were excluded. Two independent reviewers assessed the strength of evidence using the GRADE criteria and disagreements were resolved by consensus. Results: From a total of 147 possible citations, three cohort studies (class of evidence III) met our inclusion criteria and form the basis for this report. The risk of subsequent lumbar disc degeneration following standard discectomy was significantly greater compared with both microdiscectomy (48.7% vs 9.1%) and asymptomatic controls (90% vs 68%) in two studies with mean follow-ups of 5.5 and 25.3 years, respectively. Following conservative care for first-time HNP in the third study, the risk of progression of lumbar disc degeneration was 47.6% over the first 2 years of follow-up and 95.2% over the next 6 years of follow-up. In the same study, the risk of lumbar disc degeneration was shown to increase incrementally over the course of the 8-year follow-up, with all patients showing signs of degeneration at final examination. Conclusion: Standard discectomy in first-time lumbar HNP may increase the risk of subsequent same-level lumbar disc degeneration compared with microdiscectomy as seen in one low-quality study. However, disc degeneration is likely a natural, temporal consequence following HNP, as demonstrated in a second low-quality study. The overall strength of evidence for the conclusions is very low.

Study Design Systematic review. Study Rationale Neck pain is a prevalent condition. Spinal manipulation and mobilization procedures are becoming an accepted treatment for neck pain. However, data on the effectiveness of these treatments have not been summarized. Objective To compare manipulation or mobilization of the cervical spine to physical therapy or exercise for symptom improvement in patients with neck pain. Methods A systematic review of the literature was performed using PubMed, the National Guideline Clearinghouse Database, and bibliographies of key articles, which compared spinal manipulation or mobilization therapy with physical therapy or exercise in patients with neck pain. Articles were included based on predetermined criteria and were appraised using a predefined quality rating scheme. Results From 197 citations, 7 articles met all inclusion and exclusion criteria. There were no differences in pain improvement when comparing spinal manipulation to exercise, and there were inconsistent reports of pain improvement in subjects who underwent mobilization therapy versus physical therapy. No disability improvement was reported between treatment groups in studies of acute or chronic neck pain patients. No functional improvement was found with manipulation therapy compared with exercise treatment or mobilization therapy compared with physical therapy groups in patients with acute pain. In chronic neck pain subjects who underwent spinal manipulation therapy compared to exercise treatment, results for short-term functional improvement were inconsistent. Conclusion The data available suggest that there are minimal short- and long-term treatment differences in pain, disability, patient-rated treatment improvement, treatment satisfaction, health status, or functional improvement when comparing manipulation or mobilization therapy to physical therapy or exercise in patients with neck pain. This systematic review is limited by the variability of treatment interventions and lack of standardized outcomes to assess treatment benefit.

Medical Education 2012: 46: 974–982 Objectives This study was intended to examine whether a marketing research approach improves understanding of medical specialty selection by medical students. This approach likens students to consumers who are deciding whether or not to purchase a product (specialty). This approach proposes that when consumers’ criteria match their perceptions of a product’s features, the likelihood that they will purchase it (select the specialty) increases. This study examines whether exploring students’ selection criteria and perceptions of various specialties provides additional insights into the selection process. Methods Using a consumer behaviour model as a framework, a questionnaire was designed and administered to Year 6 (final-year) students in 2008 and 2009 to elicit information on their knowledge about and interests in various specialties, the criteria they used in specialty selection, and their perceptions of six specialties. Results A total of 132 (67%) questionnaires were returned. In many instances, consistency between selection criteria and perceptions of a specialty was accompanied by interest in pursuing the specialty. Exceptions were noted and pointed to areas requiring additional research. For example, although > 70% of female students replied that the affordance of a controllable lifestyle was an important selection criterion, many were interested in obstetrics and gynaecology despite the fact that it was not perceived as providing a controllable lifestyle. Minimal overlap among students reporting interest in primary specialties that possess similar characteristics (e.g. paediatrics and family medicine) demonstrated the need to target marketing (recruitment) efforts for each specialty individually. Conclusions Using marketing research concepts to examine medical specialty selection may precipitate a conceptual shift among health care leaders which acknowledges that, to attract students, specialties must meet students’ selection criteria. Moreover, if consumers (students) deem a product (specialty) unattractive, it may need to be examined further to improve its appeal.

Study design: Comparative effectiveness review. Study rationale: The spine is among the most common location for bony metastases. In many cases these metastases cause fractures leading to increased morbidity. Percutaneous cement augmentation techniques have been developed over the past decades for the treatment of these fractures; however, there are little data comparing these interventions. Clinical question: Do comparative studies of vertebral cement augmentation for fractures caused by spinal tumors provide evidence of improved patient outcomes? Methods: A systematic search and review of the literature was undertaken to identify studies published through June 8, 2011. Two individuals independently reviewed articles based on inclusion and exclusion criteria which were set a priori. Each article was evaluated using a predefined quality-rating system and an overall strength of evidence determined. Results: The literature consists primarily of case series. Only two studies comparing vertebroplasty with kyphoplasty were found. Pain scores in both treatment groups were significantly decreased relative to preoperative scores and appear to have been sustained at follow-up times to 1 year. It is unclear whether one treatment provided superior pain relief than the other. Both studies reported decreased analgesic use after both treatments but neither study compared use between treatment groups. Balloon rupture occurred in one kyphoplasty patient in one study and extravasation of polymethylmethacrylate (PMMA) cement into the anterior perivertebral soft tissue was seen in another patient in the vertebroplasty group and no patients in the kyphoplasty group in the other study. No other intraoperative or postoperative complications occurred. Conclusions: There is only limited evidence from comparative studies (two small retrospective cohort studies) regarding the benefits of vertebroplasty versus kyphoplasty in patients with spinal fractures caused by tumors. Both appear to be effective in reducing pain with relatively few complications. Whether one method provides superior results over the other cannot be determined from the available evidence. Study limitations preclude making definitive conclusions. The overall strength of evidenced is very low.

Introduction Bone is an obvious candidate tissue for stem cell therapy. This review provides an update of existing stem cell-based clinical treatments for bone pathologies. Sources of data A systematic computerized literature search was conducted. The following databases were accessed on 10 February 2011: NIH clinical trials database, PubMed, Ovid and Cochrane Reviews. Areas of agreement Stem cell therapy offers new options for bone conditions, both acquired and inherited. Areas of controversy There is still no agreement on the exact definition of 'mesenchymal stem cells'. Consequently, it is difficult to appreciate the effect of culture expansion and the feasibility of allogeneic transplantation. Growing points Based on the sound foundations of pre-clinical research, stem cell-based treatments and protocols have recently emerged. Areas timely for developing research Well-designed prospective clinical trials are needed in order to establish and develop stem cell therapy for bone diseases.

Study design: Systematic review. Study rationale: It is commonly believed that scoliosis treated nonoperatively does not worsen in pregnancy; however, at times patients with scoliosis progress rapidly during these months. Objective or clinical question: What is the level of evidence to support or deny the claim that scoliosis treated nonoperatively does not worsen in pregnancy? Methods: A systematic review of the literature was undertaken for articles published through March 2011. PubMed, Cochrane, National Guideline Clearinghouse Databases as well as bibliographies of key articles were searched. Two independent authors reviewed articles. Inclusion and exclusion criteria were set and each article was subject to a predefined quality-rating scheme. Results: We identified two articles meeting our inclusion criteria. There was no difference in risk of curve progression > 5° or > 10° between women who had one or more pregnancies compared with those who had never been pregnant. However, among women who had been treated with an orthosis, those with one or more pregnancies had a higher risk of curve progression > 5° compared with never-pregnant women: relative risk = 8.1 (95% confidence interval: 1.8–35.8) in one study and 1.9 (95% confidence interval: 0.8–4.3) in the other. While women with more severe curves had a higher risk of curve progression, having one or more pregnancies did not appear to modify the effect of curve severity. Conclusions: Having one or more pregnancies does not appear to affect curve progression in scoliosis. However, among patients who had prior orthotic treatment, there is some evidence to suggest that women experiencing one or more pregnancies had a higher risk of curve progression compared with never-pregnant women. The overall strength of evidence for this conclusion is low.

Study design: A retrospective cohort of 68 patients who underwent insertion of the DIAM (Medtronic Sofamor Danek, Switzerland) interspinous device (ISD) during 2006–2008 at one medical center. Objectives: To assess the short- and intermediate-term outcomes and complications associated with ISD. Methods: Evaluation of files and all patients who underwent insertion of a DIAM ISD was performed. Patients walking distances and pain (visual analog scale score) were compared with data gathered before surgery. Outcome and all complications related to ISD have been identified and analyzed. Results: All 68 patients were available for follow-up. Mean follow-up was 34 months (23–52 months). The average age was 57 (±13) years. Walking distance increased by 890% and patient's pain score improved by 3.27 points on visual analog scale. Twenty-one (32%) of the 68 patients had perioperative or late complications. Nine complications (75%) were unrelated to ISD and included 5 dura tears, 3 wound-related complications, and 1 transient ischemic attack. Spinous process fractures occurred in 5 cases, leading to revision in 2 cases. In total, 7 of the patients required revision surgery. These patients were older, with an average age of 69 years. Conclusion: The outcome of patients who had an implantation of the DIAM ISD is good. In this cohort, 6% developed recurrent claudication symptoms in the second postoperative year. In an older population, the combination of softer bone and rigid stenosis increase the risk of spinous process fracture, resulting in failure and leading to revision surgery. Other solutions should be sought for these patients. Final Class of evidence (CoE)-treatment Yes Study design: RCT Cohort Case control Case series • Methods Concealed allocation (RCT) Intention to treat (RCT) Blinded/independent evaluation of primary outcome F/U ≥ 85% • Adequate sample size • Control for confounding Overall class of evidence IV Open in a separate window The definiton of the different classes of evidence is available on page 55.

Foreign body (FB) injuries occur under many circumstances: at work, when practising a hobby, in car accidents, or in violence-afflicted zones. Owing to the nature of these injuries, they are not restricted to a certain part of the body and may affect several organs simultaneously. In general, an FB will be surgically removed when it is a cause of pain or infection or when jeopardizing a critical biological function. However, in many cases removing the FB is not possible owing to risk of harming adjacent delicate tissue. Furthermore, often when surgically removing the FB, microscopic fragments or debris remain at the site of invasion, becoming a cause of pain and recurring infection and inflammation. FB-related complications can also originate from micro- or nanoparticles released by degradation of medical implants. The use of advanced drug delivery technologies to target the tissue surrounding the FB, or the FB itself, may be of therapeutic benefit. Liposomes, vesicles with an aqueous core entrapped in one or more lipid bilayers, are widely used as drug delivery systems. Previous studies show that nanoliposomes can effectively target infected and inflamed tissue. The working hypothesis of this paper is that nanoliposomes, of specific lipid composition, may be used to target FB under conditions of inflammation.A comprehensive literature review regarding the use of liposomes for targeting and treating infection and inflammation, as well as a prospective on conjugates that can improve FB targeting in vivo.The article aims to assess whether nanoliposomes loaded with a therapeutic compound may be advantageous for treating FB-related pathologies.Nanoliposomes are promising candidates for targeting FB-induced infection and inflammation. Certain properties, related to the micro-anatomy and physiology of inflammation as well as to the liposome physicochemical properties, make possible 'passive' targeting of the FB region. Conjugating specific ligands to the surface of the liposomes can improve their efficacy by adding an element of 'active' targeting. Despite the great clinical need, the use of nano-based technologies to target and treat FB-induced infection, inflammation and pain has not been exploited yet. The use of drug-loaded nanoliposomes for this application seems to be most promising and should be evaluated with high priority.

Quantum dots (QDs) are fluorescent semiconductor nanocrystals with superior optical properties compared to organic dyes currently undergoing rapid development for biological applications, particularly in fluorescence imaging. The folate receptor, overexpressed in a broad spectrum of malignant tumors, is an attractive target for selective delivery of imaging agents to tumor cells. This study examines nanoparticles containing QDs entrapped in a lipid shell, and post-loaded with a folate-lipid conjugate for targeting to mouse and human tumor cells expressing the folate receptor. Hydrophobic QDs were mixed with 1,2 dipalmitoyl-sn-glycero-3 phosphocholine and methoxy-polyethylene-glycol-distearoyl-phosphatidyl-ethanolamine (mPEG-DSPE) generating a nanoparticle referred to as lipodot, with a mean diameter size of approximately 100 nm. Folate-derivatized PEG-DSPE was post-loaded into the lipodots at 0.5% lipid molar concentration. Mouse J6456 lymphoma cells (J6456-FR) and human head and neck KB cancer cells (KB-FR), up-regulated for their folate receptors, were incubated with folate-targeted and non-targeted lipodots in vitro. Using fluorescence microscopy, it was found that only folate-targeted lipodots were taken up by tumor cells. Confocal depth scanning showed substantial internalization. Confirming the specificity of folate-targeted lipodots, binding and internalization were inhibited by free folate, and no uptake was found in a folate-receptor negative cell line. Selective binding and uptake of folate-targeted lipodots by J6456-FR cells was also observed in vivo after intra-peritoneal injection in mice bearing ascitic J6456-FR tumors based on FACS analysis and confocal imaging of harvested cells from the peritoneal cavity. Folate-targeted lipodots represent an attractive approach for tumor cell labeling both in vitro and in vivo.

We report a rare case of a vertebral brown tumor causing spinal cord compression and resulting in progressive paraparesis in a 27-year-old female with end-stage renal failure, managed with hemodialysis. Urgent neurosurgical intervention and gross total resection resulted in complete resolution of the symptoms.

Because the spine and pelvis are integrated, changes in spine sagittal balance affect relative acetabulum position. A 1° change of the anterior pelvic plane changes acetabulum anteversion by 0.8°. Three-column spine osteotomies correct fixed sagittal plane deformity. Twenty patients with kyphotic deformity and associated sagittal imbalance underwent corrective 3-column osteotomy. We reviewed upright pelvic and spine radiographs preoperatively and postoperatively and documented the changes in angles. The average sagittal vertical axis was 11.07 cm preoperatively and 4.8 cm postoperatively. Lumbar lordosis changed (on average) from 39° preoperatively to 55° postoperatively (P.05). Sacral slope increased an average of 6.7° (P = .015). Pelvic tilt decreased by 5.4° (P = .001). The anterior pelvic plane increased by 8.23° (P.0001). This correction of the sagittal balance is associated with a concomitant increase in sacral slope, pelvic tilt, and the anterior pelvic plane angles. These changes will increase acetabulum anteversion by a predicted 6.54°. This increase will change acetabular cup position and must be considered in patients with spine and pelvic osteoarthritis that requires hip surgery.

Wound infection after spine surgery is a debilitating complication. Local placement of vancomycin powder into the surgical wounds prior to closing of the fascia has been introduced as a method to reduce deep infection rates. The infection rates of all the patients who were treated with intra-operative local vancomycin between June 2012 and June 2013 were compared to all cases that were not treated with vancomycin between January 2009 and December 2010. Patients for both groups were operated by four senior, fellowship-trained spine surgeons with a combined experience of 55 years of practice at a referral orthopedic center. Patients’ charts and microbiology reports were reviewed. 1224 cases were performed with the use of vancomycin. The average age was 56.3 years (SD −13.2; NS). The male to female ratio was 1:1.12 (NS). 2253 cases were performed without the use of vancomycin. The average patient age was 57.1 years (SD 14.5). The male to female ratio was 1:1.14. There were 30 cases of deep infections needing a surgical irrigation and debridement without vancomycin versus 5 when vancomycin was used (P = 0.04). Infections in patients treated with vancomycin were not vancomycin-resistant bacteria. In conclusion, the use of vancomycin reduces the rate of deep wound infections and irrigation and debridement procedures after spine surgery in a referral center among surgeons with a high surgical volume.

We aimed to assess the efficacy of surgical decompression of metastatic epidural spinal cord compression (MESCC) in patients ≧65 years and review our multidisciplinary surgical decision-making process.We identified all patients operated for MESCC from August 2008 to June 2012. Patients ≧65 years, with a single area of cord compression, back/radicular pain, neurological signs of cord compression, surgery within 48 hours after onset of MESCC-related paraplegia, and follow-up for ≧1 year or until death were included. Files were reviewed retrospectively. The requirement for informed consent was waived. Neurological status was assessed with the American Spinal Injury Association (ASIA) Impairment Scale (AIS). Duration of ambulation and survival were assessed with Kaplan-Meier and Cox regression analysis.Twenty-one patients met inclusion criteria (11 women/10 men; mean age 73 years, range 65-87). All presented with debilitating back/neck pain. Ten patients (48%) were not ambulatory before surgery and four suffered urinary incontinence/constipation (19%). Preoperative AIS was E in 5 patients (24%), D in 11 (62%), and C in 5 (24%). Motor symptoms had been present for a mean of 3·8 days (range 1-14). All patients regained ambulation. Overall, mean survival was 320 days (range 19-798) and mean ambulation was 302 days (range 18-747). On 31 March 2013, 7 patients (33%) were alive and ambulatory at a mean of 459 days (range 302-747); 14 patients had died (67%) at a mean of 251 days (range 19-798), with a mean ambulation of 223 days (range 18-730).With careful patient selection, surgery may achieve long duration of ambulation in patients ≧65 years with MESCC.

The advent of spinal instrumentation allowed spine surgeons to treat complex spinal pathologies while maintaining or correcting alignment and maintaining or restoring spinal stability. Pedicle screws became an integral part of these complex procedures [1]. As spinal procedures progressed and became more complex, misplacement of pedicle screws, with the attendant risk of injury to the spinal cord, nerve roots, great vessels, or visceral tissue, or loss of mechanical stability, became a factor influencing surgical outcome.

The sacro-iliac joint (SIJ) is the largest joint in the human body. When the lumbar spine is fused to the sacrum, motion across the SIJ is increased, leading to increased degeneration of the SIJ. Degeneration can become symptomatic in up to 75% of the cases when a long lumbar fusion ends with a sacral fixation. If medical treatments fail, patients can undergo surgical fixation of the SIJ.This study reports the results of short-term complications, length of stay, and clinical as well as radiographic outcomes of patients undergoing percutaneous SIJ fixation for SIJ pain following long fusions to the sacrum for adult scoliosis.A retrospective review of all the patients who underwent a percutaneous fixation of the SIJ after corrective scoliosis surgery was performed in a single specialized scoliosis center between the years 2011-2013. Ten SIJ fusions were performed in six patients who failed conservative care for SIJ arthritis. Average age was 50 (range 25-60 years). The patients were 15.3 years in average after the original surgical procedure (range 4-25 years). Average post-operative follow-up was 10.25 months (range 15-4 months). The medical charts of the patients were reviewed for hospital stay, complications, pre- and post-operative pain, quality of life, and satisfaction with surgery using the visual analogues score (VAS), Scoliosis Research Society (SRS)22 and Oswestry Disability Index (ODI) questionnaires. Images were reviewed for fixation of the SIJ, fusion, and deviation of the implants from the SIJ.There were no complications in surgery or post-operatively. Discharge was on post-operative day 2 (range 1-4 days). Leg VAS score improved from 6.5 to 2.0 (P 0.005; minimal clinically important difference (MCID) 1.6). Back VAS score decreased from 7.83 to 2.67 mm (P 0.005; MCID 1.2). ODI scores dropped from 22.2 to 10.5 (P = 0.0005; MCID 12.4). SRS22 scores increased from 2.93 to 3.65 (P = 0.035; MCID 0.2) with the largest increases in the pain, function, and satisfaction domains of the questionnaires.Fixation of the SIJ in patients that fail conservative care for SIJ arthritis after long fusions ending in the sacrum provides a reduction in back pain and improved quality of life in the short and medium range follow-up period.

STUDY DESIGN Prospective patient series. OBJECTIVE To evaluate outcome of children experiencing severe osteogenesis imperfecta (OI) with thoracic insufficiency syndrome (TIS), who were treated with a novel expandable spinothoracic fixation device. SUMMARY OF BACKGROUND DATA Current treatment options for TIS in patients with OI are limited. As in other patients with TIS, thoracic elongation is the treatment of choice; however, the use of vertical expandable prosthetic titanium rib device is contraindicated for patients with poor bone quality. METHODS From 2007 to 2009, 4 patients with type III OI with TIS, aged 8 to 12 years, were treated with a novel expandable spinothoracic fixation device. Pre- and postoperative mobility, Cobb angle, PO2, PCO2, forced vital capacity, forced expiratory flow, use of accessory muscles when breathing, body weight, complication rates, and patient satisfaction were assessed. RESULTS Prior to surgery, 2 patients were wheelchair bound and 2 walked with assistive devices. Average follow-up was 24 months (range, 14-36 mo). Mean Cobb angle improved by up to 32% in the coronal plane. Pulmonary function improved in all patients, with mean increases of 45% in forced vital capacity, 93% in forced expiratory flow, and 43% in PO2. PCO2 declined 30% on average, returning to normal values. Mean patient weight at 6-month follow-up increased by 10.9%. Patients moved from less than 3rd weight percentile per age group to the 3rd to 7th percentiles at the 6-month follow-up, with continuing weight gain. There were no major complications. All patients and their caregivers were satisfied that the procedure led to improved self-image and functional level. CONCLUSION Thoracic elongation improved pulmonary function, facilitated weight gain, and made an indirect correction of spinal deformities (Cobb angle) by more than 30%, with no significant complications. Because of the rarity of this condition, a multicenter study to gain experience in a larger number of patients is recommended.

Study design: A retrospective case series of patients with myelomeningocele (MMC) who underwent kyphectomy and posterior segmental fixation using Luque rods and 16-gauge wires. Objective: To assess outcomes after posterior kyphectomy and segmental fixation for kyphosis in patients with MMC. Methods: Thirteen consecutive patients who underwent posterior kyphectomy for transforaminal fixation contiguous to “everted lamina.” Fusion rates, time to fusion, change in Cobb angle, complications, and improvement in activities of daily living using the Katz score were measured. Results: Average age at time of surgery was 9.2 (range, 4.5–17) years. Average time to follow-up was 120 (range, 20–310) months. Solid fusion was achieved in 9 patients (69%) with a mean time to fusion of 12 months. The mean postoperative kyphotic curve was 22° with an average correction of 90°. Five patients (38%) experienced a postoperative complication. The mean improvement in activities of daily living score was 1.6 points and all patients achieved independent sitting balance. Conclusion: Segmental spino-pelvic fixation is a solid alternative mode of fixation in patients with MMC with congenital kyphosis. Patient selection, proper perioperative multidisciplinary assessment, and surgeons' expertise are significant in the success of this complex surgery. Methods evaluation and class of evidence (CoE) Study design: Prospective cohort Retrospective cohort Case control Case series • Methods Patients at similar point in course of treatment • Follow-up ≥ 85% • Similarity of treatment protocols for patient groups • Patients followed-up long enough for outcomes to occur Control for extraneous risk factors Overall class of evidence IV The definiton of the different classes of evidence is available on page 63. View it in a separate window STUDY RATIONALE Thoracolumbar kyphosis occurs in 10–20% of patients with myelomeningocele (MMC) 1,2,3. Curves are congenital and rigid, larger than 80° at birth and progressing to more than 100° 4. These lead to chronic pressure sores, impaired sitting balance, collapsing spine phenomena, decreased abdominal capacity, and reduced respiratory function 4. There is no consensus regarding the proper mode of correction in patients with MMC 5.

A new class of nanogel demonstrates modular biodistribution and affinity for bone. Nanogels, ~70 nm in diameter and synthesized via an astoichiometric click-chemistry in-emulsion method, controllably display residual, free clickable functional groups. Functionalization with a bisphosphonate ligand results in significant binding to bone on the inner walls of marrow cavities, liver avoidance, and anti-osteoporotic effects., National Institutes of Health (U.S.) (RO1 DE016516), National Institutes of Health (U.S.) (R01 EB000244), Damon Runyon Cancer Research Foundation (DFS-#2050-10)

Gunshot wounds (GSWs) to the spine used to be a rare event, but with the increase of small arm intercity trauma, GWSs have increased to account for 13 to 17% of all spine injuries.1 The classic patient is a 30-year-old man from a low-income background who got into a fight and ends up in the hospital after being shot with a pistol.2 Most of these injuries cause devastating harm. The extent of injury depends on the level of entrance and the trajectory the bullet took in the spine. Most gunshot injuries are at the thoracic levels of the spine, with lower rates in the cervical and lumbar spine. In cervical cases, most patients are quadriplegic, but in the cauda equine, patients who come in with an incomplete spinal cord injury have a favorable outcome.3 Moisi et al presented a case in which the bullet caused worsening leg symptoms that led to the removal of the fragment with an immediate improvement in patient's symptoms. The care of the patient presenting with a spinal GSW is similar to any penetrating injury; it is managed according to the Advanced Trauma Life Support guidelines,5 in which the patient is evaluated according to life-threatening conditions using “ABCDE” (airway, breathing, circulation, disability, and exposure).4 Only after the primary survey is completed should the spinal lesion be treated. Most GSWs to the spine are not isolated injuries, and these penetrating injuries cause multiorgan damage leading to emergent surgical intervention. The care to the spinal injury includes tetanus vaccination unless the patient was known to have received the vaccination in the past 5 years and broad-spectrum antibiotics for 48 to 72 hours; these antibiotics should be modified according to the adjacent organs that are injured from the GSW. Surgical treatment of GSWs in the spine remains controversial. The only absolute indication for surgery in spinal GSW is the presence of progressive neurologic deficit associated with compression of neural elements in imaging examinations or a fistula of cerebrospinal fluid leading to the skin or the pleura.3 Incomplete injuries without deterioration have been shown to improve in over 70% even without surgery, so surgery is not needed on a routine basis. In cases in which the GSW causes instability to the spine, stabilization and at times decompression is needed. Other indications for surgery are a bullet location that is at risk for migration (inside the disk or intracanal) and toxicity (articular or intracanal). Unlike the case presented here, the removal of the bullet is not often associated with the resolution of the pain,3 which requires the administration of drugs, such as tricyclic antidepressants and neuroleptic medication. In summary, the increase of GSWs has led to a surge in spinal cord injuries that may need more care and surgery by the hospital team. Sadly, the prognosis of the spinal cord injury is determined more by the injury and less by the care given in the hospital, and surgical intervention should be considered only in indicated cases.

Background Hyperglycaemia and diabetes mellitus are common in patients hospitalized in the orthopaedic surgery ward. However, glycaemic control obtained during hospitalization is often suboptimal. No method for achieving adequate glycaemic control in this population has been validated in an in-hospital setting. Intervention An intervention including an intensive subcutaneous insulin protocol in the orthopaedic department. Methods All diabetic patients admitted to the Department of Orthopaedic Surgery were prospectively randomized during a 6-month period. One group (n = 30) received standard care with sliding scale insulin and the other group (n = 35) received the intervention protocol. During the intervention period, the staff was briefed on the importance of glucose monitoring and control. An intensive multiple-injection protocol consisting of four daily regular/neutral protamine hagedorn (NPH) insulin injections was initiated in diabetic patients. The programme was followed up by a consulting diabetologist. Results Mean blood glucose levels throughout the hospitalization were 161.48 ± 3.8 mg/dL in the intervention group versus 175.29 ± 2.3 mg/dL in the control group (p < 0.0005). Hospitalization was shorter by 2 days in the intervention group (p < 0.05). The number of severe hyperglycaemic events (blood glucose level above 400 mg%) was significantly lower (p < 0.05) in the intervention group. There was no significant difference in the number of hypoglycaemic events. Conclusions The suggested four-step intervention regimen improved glycaemic control of hospitalized patients in the orthopaedic department and simplified the ‘in-house’ treatment of the diabetic patient. Hospital stays were reduced on average by two days (p < 0.05). Copyright © 2011 John Wiley & Sons, Ltd.

Multi-casualty events are characterized by a large number of wounded people arriving at trauma centers in a short period of time. These wounded suffer distinctive injuries in accordance with the cause of the event. Close to 50 percent of all injuries in a multi-casualty event are musculoskeletal injuries. These injuries are not usually isolated and indicate that the patient has suffered severe trauma. Correct management of such an event requires proper management in the pre-hospital, trauma centers, wards and operating galleries. A "damage control" policy should be implemented in all stages of the patient's care. Orthopedic care has been revolutionized several times--developing from delayed care, to early total care and finally to "damage control" orthopedics. "Damage control" orthopedics emphasizes initial stabilization and control of injuries, due to the systemic cytokine storm after polytrauma, prior to final corrective surgery of the patient's fractures. In this article the authors review the orthopedic care in a multi-casualty event, and the specific care given to each of the wounded in such an event.

The musculoskeletal system is the largest system within the human body. Different components of this system have different capabilities in terms of healing and regeneration. In this process, stem cells arrive at the site of the injury creating natural tissue or scar tissue. However, at times, the injury is greater than the healing capability of the tissue, and medical and biological interventions are required in order to enhance healing. In the classical scenario, bone-derived stem cells are harvested from the bone marrow and placed at the injury site with different supplements driving the stem cells toward the tissue which we aim to regenerate. This process is limited by the small amount of stem cells in the bone marrow and by the morbidity associated with the harvesting procedure. Therefore, alternative sources of stem cells are being sought. Adipose tissue comprises many stem cells, which with the proper triggering can be converted to osteoblasts, chondrocytes, tenocytes, and myoblasts. In this chapter, we review the current data regarding the in vitro and in vivo work being done with adipose-derived stem cells and their use in orthopedic applications.

Over the last decades, the medical world has advanced dramatically in the understanding of fracture repair. The three components needed for fracture healing are osteoconduction, osteoinduction and osteogenesis. With newly designed scaffolds, ex vivo produced growth factors and isolated stem cells, most of the challenges of critical size bone defects have been resolved in vitro, and in some cases in animal models as well. However, there are still challenges needed to be overcome before these technologies can be fully converted from the bench to the bedside. These technological and biological advancements need to be converted to mass production of affordable products that can be used in every part of the world. Vascularity, full substation of scaffolds by native bone, and bio-safety are the three most critical steps to be challenged before reaching the clinical setting.

Varicella Zoster (VZV), a virus from the Herpesviridae virusfamily, comprises large enveloped, double-stranded DNAvirus [1]. VZV commonly infects children. It manifests aschickenpox, a generalized vesicular rash. Nearly 90% of casesoccur before the age of 10. In the healthy population VZV isassociated with little morbidity or mortality. In immunocom-primized patients Varicella can cause life threatening com-plications; encephalitis, pneumonitis, bacterial super-infectionanddehydration[2].Therehavebeenseveralreportsregarding generalized VZV infections in immunosuppressedpatients, mainly postrenal transplant patients [2].There are only a few cases of reported Varicella infectionsin burn patients [3,4], all in pediatric burn patients. Here wereportfor the first timea caseof Varicellainfectioninan adultburn patient.

IntroductionIn the past decades, there has been an increasing interest in quality of life assessment after treatment of adolescent idiopathic scoliosis. Scoliosis affects young patients many of the...