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Background Although venous thromboembolism (VTE) is a potentially serious and life-threatening complication, there is no widely accepted protocol to guide VTE prophylaxis in adult degenerative spinal surgery, and pharmacologic overtreatment may result in hemorrhagic complications. Previously, we published the VTE Prophylaxis Risk/Benefit Score, an evidence-based algorithm that balances the risk and consequences of thrombotic versus hemorrhagic complications by taking consideration of patient-related risks, procedure-related risks, and the risk of neurological compromise to guide VTE prophylaxis. To objective of this study was to validate the VTE Prophylaxis Risk/Benefit Score. Methods From January 1, 2016, to December 31, 2017, VTE Prophylaxis Risk/Benefit Scores and corresponding prophylaxes were prospectively assigned. When indicated, chemoprophylaxis was dosed 24 to 36 hours postoperatively to allow for adequate surgical hemostasis. Patients were retrospectively evaluated for immediate and short-term complications. The Fisher exact test compared incidence of complications by VTE prophylaxis. Multinomial logistic regression modeled the probability of complication by prophylaxis type, demographics, and comorbidities. Significance was set at P Results Of the 266 patients who met inclusion criteria, 79.3% were given mechanical prophylaxis alone and 20.7% were given combined mechanical and chemical prophylaxis. Complications including VTE (0.38%), delayed wound healing or infection (2.26%), and hematoma (0.75%) were observed at rates similar to or lower than previously published studies with increased utilization of chemoprophylaxis. Use of chemoprophylaxis and continuation of perioperative aspirin were significantly associated with the development of a hemorrhagic complication. No patient developed persistent neurologic deficit from hematoma or pulmonary embolism. Conclusions The VTE Prophylaxis Risk/Benefit Score comprehensively considers the risk of thrombotic, wound, and bleeding complications and is an effective tool for determining appropriate thromboprophylaxis in adult degenerative spinal surgery. Level of Evidence 3.

Study design Patellar tendon reflexes were elicited among patients who had had a unilateral total knee replacement, those planned for unilateral total knee replacement, and a cohort of controlled patients. Patellar tendon reflex (PTR) response was measured with surface electromyography. Objective The aim of this study was to determine if total knee arthroplasty significantly alters the PTR. Summary of background data As part of the clinical evaluation of the spine, extremity reflexes are provoked. Reflex variation between right and left extremities can be a pathological finding in disease of the spine. It has been noted that in patients who have undergone total knee arthroplasty (TKA), the PTR is diminished on the operative side compared with the contralateral nonoperative side. PTR is part of the clinical exam when evaluating a patient for lumbar radiculopathy. Methods The right and left patellar tendon reflex intensities were measured by quadriceps surface electromyography in 3 groups of patients. Group 1 consisted of 21 patients with unilateral TKA who were at least 6 months postoperative. Group 2 consisted of 18 patients with unilateral severe knee arthritis indicated for TKA. Group 3, serving as the control group, included 20 patients with no evidence of knee arthritis in either knee. The average reflex response for each group was recorded and comparisons were then made between each group. Results Patients who have undergone unilateral TKA have a PTR on average of 55.1% of their contralateral uninvolved side. This is statistically significant when compared with reflexes in patients who are planned for unilateral total knee arthroplasty, 96.03% (P = 0.001) and when compared with patients without evidence for knee arthritis, 102.2% (P Conclusion The results of this case control study show that TKAs do significantly diminish PTRs when compared with a contralateral uninvolved knee in the same patient. Level of evidence 3.

The incidence of intraoperative complications during cervical spine surgery is low; however, if they do occur, intraoperative complications have the potential to cause considerable morbidity and mortality. Spine surgeons should be familiar with methods to minimize intraoperative complications. If they do occur, surgeons must be prepared to immediately treat each potential complication to reduce any associated morbidity.

Study design Retrospective radiographic analysis. Objective To retrospectively review a group of patients undergoing anterior cervical discectomy and fusion (ACDF) to determine the relative risk of adjacent level disc degeneration after incorrect needle localization. Summary of background data The needle puncture technique is a well-established method to cause disc degeneration in experimental animal studies. The risk for accelerated degeneration because of needle puncture in humans is unknown. Methods A retrospective radiographic analysis of 87 consecutive patients after single or 2-level ACDF with anterior plate instrumentation was performed. Perioperative and follow-up radiographs were used to grade disc degeneration according to a previously described scale. Results Eighty-seven patients were included in the study (36 underwent 1-level ACDF, and 51 underwent 2-level ACDF). Seventy-two had correct needle localization at the level of planned surgery; 15 had incorrect needle localization (1 level above the operative level). There were no differences between the 2 groups in age, sex and length of follow-up. Patients in the incorrectly marked group were statistically more likely to demonstrate progressive disc degeneration with an odds ratio of 3.2. There was no correlation between age and length of follow-up with development of disc degeneration. Conclusion There is a 3-fold increase in risk of developing adjacent level disc degeneration in incorrectly marked discs after ACDF at short-term follow-up. This may indicate that either needle related trauma or unnecessary surgical dissection contributes to accelerated adjacent segment degeneration.

Background context The posterior ligamentous complex (PLC) is thought to contribute significantly to the stability of thoracolumbar spine. Obvious translation or dislocation of an interspace clearly denotes injury to the PLC. A recent survey of the Spine Trauma Study Group indicated that plain radiographic findings, if present, are most helpful in determining PLC injury. However, confusion exists when plain radiography shows injury to the anterior spinal column without significant kyphosis or widening of the posterior interspinous space. Purpose The objective of this study is to identify imaging parameters that may suggest a disruption of the posterior ligamentous complex of the thoracolumbar spine in the setting of normal-appearing plain radiographs. This study was performed, in part, as a pilot study to determine critical imaging parameters to be included in a future prospective, randomized, multicenter study. Study design/setting Survey analysis of the Spine Trauma Study Group. Patient sample None. Outcome measures Compilation and statistical analysis of survey results. Methods Based on a systematic review of the English literature from 1949 to present, we identified a series of traits not found on plain X-rays that were consistent with PLC injury. This included five imaging findings on either computed tomography (CT) scans or magnetic resonance imaging (MRI) and several physical examination features. These items were placed on a survey and sent to the members of the Spine Trauma Study Group. They were asked to rank the items from most important to least important in representing an injury to the PLC in the setting of normal-appearing plain radiographs. Results Thirty-three of 47 surveys were returned for final analysis. Thirty-nine percent (13/33) of the members ranked “disrupted PLC components (i.e., interspinous ligament, supraspinous ligament, ligamentum flavum) on T1 sagittal MRI” as the most important factor in determining disruption of PLC. When analyzed with a point-weighted system, “diastasis of the facet joints on CT” received the most points, indicating that this category was ranked high by the majority of the members of the group. The members were also given freedom to add other criteria that they believed were important in determining PLC integrity in the setting of normal-appearing plain radiograph. Of the other criteria suggested, one included a physical finding and the other a variant of MR sequencing. Conclusions In a setting of normal-appearing plain radiographs, PLC injury as displayed on T1-weighted MRI and diastasis of the facet joints on CT scan seem to be the most popular determinants of probable PLC injury among members of the Spine Trauma Study Group. Between MRI and CT scan, most members feel that various characteristics on MRI studies were more helpful.

Wound infection after surgical treatment of traumatic spinal injuries is twice more common than after elective spinal surgery. Risk factors include older age, complete neurologic injury, more extensive surgery, posterior surgery, use of high-dose steroids, and prolonged stay in the intensive care unit. Modifiable risk factors should be minimized in the preoperative, intraoperative, and postoperative periods. The key to treatment is prompt irrigation and debridement. Because of the high prevalence of polymicrobial infections, broad-spectrum antibiotics should be administered.

Distinguishing between the normal gait of the elderly and pathologic gaits is often difficult. Pathologic gaits with neurologic causes include frontal gait, spastic hemiparetic gait, parkinsonian gait, cerebellar ataxic gait, and sensory ataxic gait. Pathologic gaits with combined neurologic and musculoskeletal causes include myelopathic gait, stooped gait of lumbar spinal stenosis, and steppage gait. Pathologic gaits with musculoskeletal causes include antalgic gait, coxalgic gait, Trendelenburg gait, knee hyperextension gait, and other gaits caused by inadequate joint mobility. A working knowledge of the characteristics of these gaits and a systematic approach to observational gait examination can help identify the causes of abnormal gait. Patients with abnormal gait can benefit from the treatment of the primary cause of the disorder as well as by general fall-prevention interventions. Treatable causes of gait disturbance are found in a substantial proportion of patients and include normal-pressure hydrocephalus, vitamin B(12) deficiency, Parkinson's disease, alcoholism, medication toxicity, cervical spondylotic myelopathy, lumbar spinal stenosis, joint contractures, and painful disorders of the lower extremity.

Venous thromboembolic embolism (VTE) is a potentially serious and life-threatening complication in spine surgery. However, VTE incidence and prophylaxis in spine surgery remains controversial. Current recommendations for VTE prophylaxis address "spine surgery" as a single broad category and mainly consider patient factors when determining risk. We performed a literature review to determine the varying VTE and bleeding risks within spine surgery to develop an individualized prophylactic algorithm. Our review suggests that the current guidelines on VTE prophylaxis for spine surgery from NASS and ACCP are suboptimal. Consideration of (1) patient-related VTE risks, (2) procedure-related VTE risks, and (3) the risk of neurological compromise from bleeding complications will more appropriately balance safety and effectiveness when choosing a VTE prophylaxis method. To better individualize VTE prophylaxis, we have developed the VTE Prophylaxis Risk/Benefit Score that considers this currently available best evidence to arrive at a recommendation for the most appropriate form of VTE prophylaxis. This algorithm informs the surgeon to help make a more nuanced and individualized determination of prophylaxis.

Book Review by Pierre Kehr • Bone graft substitutes: Mesenchymal stem cells remain an area of interest, though the amount of cells needed to elicit a bonehealing response as well as what triggers need to be expressed by the cells is unknown. • Disc degeneration: biologic treatments in this space are developing at a "slow pace," though a human trial evaluating BMP delivery to discs to prevent degeneration is in development.

Study design A retrospective review of neurophysiologic alerts during anterior cervical surgery. Objectives To examine incidence and types of neurophysiologic alerts and their correlation with new postoperative neurologic deficits after anterior cervical discectomy or corpectomy procedures. Summary of background data Although multimodality neurophysiologic monitoring has been shown to predict iatrogenic neurologic injuries in scoliosis surgeries, their role in degenerative or trauma-related anterior cervical spine surgery is still unclear. Materials and methods We retrospectively reviewed 1,445 patients who underwent anterior cervical discectomy or corpectomy and arthrodesis with neurophysiologic monitoring that included transcranial electrical motor-evoked potentials (tceMEP), somatosensory-evoked potentials (SSEP), and spontaneous electromyography (EMG). Intraoperative alerts were analyzed for type, perceived cause, actions taken to reverse or minimize the possible spinal cord injury, and any new postoperative neurologic deficits. Results There were 267 (18.4%) procedures that had either minor (spontaneous, sustained EMG) or major (tceMEP/SSEP amplitude reduction) alerts. Patients who underwent corpectomies had 28% increased risk of having a major neurophysiologic alert compared with those who had discectomies. Diagnosis of cervical spondylotic myelopathy or trauma increased the risk of having a major neurophysiologic alert 30% and 76%, respectively, compared with cervical radiculopathy. Eight surgeries were aborted due to persistent tceMEP/SSEP amplitude loss, but none resulted in new postoperative neurologic deficits. Two patients had halo-vest applied due to early termination of surgery. One of these patients ultimately could not receive definitive surgical stabilization. Discussion and conclusion Diagnosis of cervical spondylotic myelopathy or trauma and cervical corpectomy procedures increase the risk for having major intraoperative alerts. In case of persistent tceMEP/SSEP amplitude loss, consider delaying potentially harmful interventions, such as premature termination of the procedure or methylprednisolone infusion, until a new neurologic deficit is verified with an awake-clinical examination.

Spine specialists continue to debate how to best treat various types of thoracolumbar injuries. The first step in standardizing optimal treatment is for orthopedists, neurosurgeons, and rehabilitation specialists to arrive at a consensus regarding the classification of thoracolumbar fractures. Beginning with Bohler in 1931, there have been several attempts to forward thoracolumbar injury classifications systems since the advent of the radiograph. Throughout this period, surgeons and other health care providers have debated whether an effective injury classification system should be based upon the mechanism of injury or the morphology of injured tissues. A systematic review of the literature on thoracolumbar spine trauma classification systems, emphasizing contrasting features of mechanistic and morphometic paradigms, was conducted by 40 spine surgeons from 15 trauma centers in 10 countries. As a contemporary example of this debate, we also discuss 2 recently validated thoracolumbar-fracture classification...

Study design Prospective study of 5 spine surgeons rating 71 clinical cases of thoracolumbar spinal injuries using the Thoracolumbar Injury Severity Score (TLISS) and then re-rating the cases in a different order 1 month later. Objective To determine the reliability of the TLISS system. Summary of background data The TLISS is a recently introduced classification system for thoracolumbar spinal column injures designed to simplify injury classification and facilitate treatment decision making. Before being widely adopted, the reliability of the TLISS must be studied. Methods A total of 71 cases of thoracolumbar spinal trauma were distributed on CD-ROM to 5 attending spine surgeons, including clinical/radiographic data, details of the TLISS, and a scoring sheet in which cases would be scored using the system. The surgeons were later assigned the task with the cases reordered. Intraobserver and interobserver reliability was calculated for TLISS components, total score, and surgeon's treatment decision using the Cohen unweighted kappa coefficients and Spearman rank-order correlation. Results Interrater reliability assessed by generalized kappa coefficients was 0.33 +/- 0.03 for injury mechanism, 0.91 +/- 0.02 for neurologic status, 0.35 +/- 0.03 for posterior ligamentous complex status, 0.29 +/- 0.02 for TLISS total, and 0.52 +/- 0.03 for treatment recommendation. Respective results using the Spearman correlation were 0.35 +/- 0.04, 0.94 +/- 0.01, 0.48 +/- 0.04, 0.65 +/- 0.03, and 0.51 +/- 0.04. Surgeons agreed with the TLISS recommendation 96.4% of the time. Intrarater kappa coefficients were 0.57 +/- 0.04 for injury mechanism, 0.93 +/- 0.02 for neurologic status, 0.48 +/- 0.04 for posterior ligamentous complex status, 0.46 +/- 0.03 for TLISS total, and 0.62 +/- 0.04 for treatment recommendation. Respective results using the Spearman correlation were 0.70 +/- 0.04, 0.95 +/- 0.02, 0.59 +/- 0.05, 0.77 +/- 0.04, and 0.59 +/- 0.05. Conclusions The TLISS has good reliability and compares favorably to other contemporary thoracolumbar fracture classification systems.

Background context There are no published studies on the relationship between total disc replacement (TDR) motion and the development of adjacent level degeneration (ALD). Because prevention of ALD is the underlying justification for TDR, studies investigating the validity of this concept are essential. Purpose To examine the relationship between range of motion (ROM) and ALD 8.7 years after lumbar TDR. Study design/setting Retrospective radiographic and chart review. Patient sample Forty-two patients 8.7 years after lumbar TDR. Outcome measures Radiographic flexion-extension and ALD. Modified Stauffer-Coventry score. Oswestry Disability Questionnaire. Subjective patient ratings of back pain, leg pain, and disability. Methods We reviewed the flexion-extension radiographs of 42 patients 8.7 years after TDR. Cephalad adjacent levels were evaluated for degeneration: loss of disc space height, anterior osteophyte formation, or dynamic flexion-extension instability. Graphical analysis of motion and the prevalence of ALD was performed. A statistical relationship between ALD and clinical outcome was sought. Results Ten of 42 patients evaluated (24%) had radiographic ALD. The mean motion was 3.8°±2.0°. The patients with ALD had mean motion of 1.6°±1.3° whereas the patients without ALD had motion of 4.7°±4.5° (p=.035). A clear relationship between motion and the presence of ALD at 8.7-year follow-up was observed. Patients with motion 5° or greater (n=13) had a 0% prevalence of ALD. Patients with motion less than 5° (n=29) had a 34% prevalence of ALD (p=.021, odds ratio 13.5). ALD had no statistically significant effect on clinical outcome although the sample size was small. Conclusions At 8.7-year follow-up, the prevalence of ALD after TDR is higher in patients with motion less than 5°. The presence of ALD had no significant effect on clinical outcome, but the sample size was small. These data suggest that patients with significant ROM after lumbar TDR may have reduced risk for radiographic ALD.

STUDY DESIGN A retrospective review of lumbar total disc replacement (TDR) radiographs. OBJECTIVE To determine the error and variability in measuring TDR radiographic range of motion (ROM). SUMMARY OF BACKGROUND DATA Motion preservation is the driving force behind lumbar TDR technology. In the recent literature, sagittal radiographic TDR ROM as low as 2 degrees has been reported. In these studies, ROM was determined by using the Cobb method to measure TDR sagittal alignment angles in flexion-extension lateral radiographs. However, previous studies in the spinal deformity literature have shown that the Cobb method is very susceptible to measurement error. METHODS There were 5 observers, including 2 attending orthopedic spine surgeons, 1 spine fellow, 1 fifth-year resident, and 1 fourth-year resident, who measured the ROM of 50 ProDisc II (Synthes Spine Solutions, New York, NY) TDRs on standard flexion-extension lumbar spine radiograph sets. Repeated measurements were made on 2 occasions using the Cobb method. Measurement variability was calculated using 3 statistical methods. RESULTS The 3 statistical methods resulted in extremely similar values for TDR ROM observer variability. Overall, the intraobserver variability of TDR ROM measurement was +/-4.6 degrees, and interobserver variability was +/-5.2 degrees . CONCLUSIONS To be 95% certain that an implanted TDR prosthesis has any sagittal motion, a ROM of at least 4.6 degrees must be observed, which is the upper limit of intraobserver measurement variability for a TDR with a true ROM of 0 degrees. To be 95% certain that a change in TDR ROM has occurred between 2 measurements by the same observer, a change in ROM of at least 9.6 degrees must be observed (the entire range of +/-4.6 degrees intraobserver variability). ROM measurement variability should be considered when evaluating the success or failure of motion preservation in lumbar TDR.

Patients with acute spinal injury who require operative intervention may be at increased risk for postoperative surgical-site infection when compared with patients having elective spinal surgery. Various local, systemic, and iatrogenic factors predispose this unique population of patients to post-surgical infection. Nonmodifiable risk factors for surgical-site infection in spine trauma include age, medical comorbidities, and neurologic status. Modifiable risk factors include poor postoperative nutritional status, delay from time of injury to surgical intervention, posterior surgical approach, higher number of levels stabilized, length of postoperative stay in the intensive care unit, and treatment by a single specialty team (versus treatment by successive orthopaedic and neurosurgical teams). When treating patients with spine trauma, a high index of suspicion should be maintained for patients with multiple risk factors for infection and every effort should be made to minimize the modifiable risk factors.Level V (expert opinion). Please see the Guidelines for Authors for a complete description of levels of evidence.

ObjectA new classification and treatment algorithm for thoracolumbar injuries was recently introduced by Vaccaro and colleagues in 2005. A thoracolumbar injury severity scale (TLISS) was proposed for grading and guiding treatment for these injuries. The scale is based on the following: 1) the mechanism of injury; 2) the integrity of the posterior ligamentous complex (PLC); and 3) the patient’s neurological status. The reliability and validity of assessing injury mechanism and the integrity of the PLC was assessed.MethodsForty-eight spine surgeons, consisting of neurosurgeons and orthopedic surgeons, reviewed 56 clinical thoracolumbar injury case histories. Each was classified and scored to determine treatment recommendations according to a novel classification system. After 3 months the case histories were reordered and the physicians repeated the exercise. Validity of this classification was good among reviewers; the vast majority (> 90%) agreed with the system’s treatment recommendations. Surgeons were unclear as to a cogent description of PLC disruption and fracture mechanism.ConclusionsThe TLISS demonstrated acceptable reliability in terms of intra- and interobserver agreement on the algorithm’s treatment recommendations. Replacing injury mechanism with a description of injury morphology and better definition of PLC injury will improve inter- and intraobserver reliability of this injury classification system.

R ecombinant human bone morphogenetic protein-2 (rhBMP-2) has been tested as a bone-graft substitute in randomized, prospective clinical trials since 19971-4. In certain procedures, its efficacy with regard to both arthrodesis rates and clinical outcome has equaled that obtained with iliac crest bone graft. The United States Food and Drug Administration recently approved the use of rhBMP-2 as a bone-graft replacement during anterior lumbar interbody arthrodesis in conjunction with a tapered, threaded intervertebral cage (LT-CAGE; Medtronic Sofamor Danek, Minneapolis, Minnesota). Although the Food and Drug Administration has approved the use of rhBMP-2 only in conjunction with the LT-CAGE device, an off-label use of rhBMP-2 with structural allograft bone in anterior lumbar interbody arthrodesis has been reported. A pilot clinical trial in which allograft bone dowels and an rhBMP-2-soaked absorbable collagen sponge were used for lumbar interbody arthrodesis demonstrated favorable outcomes and good arthrodesis rates3. There have been some concerns about the potential up-regulation of osteoclastic activity leading to rapid resorption of the allograft when the allograft is used with rhBMP-2. Some of this concern originates from the fact that rhBMP-2 can stimulate differentiation and enhance survival of some populations of osteoclasts5. However, thus far, this concern has not been clearly validated in basic science or clinical investigations. In fact, rhBMP-2 has been used to enhance healing of allograft fractures in rats6 and to enhance the biomechanical properties of allograft-native bone interface in dogs7. We report a case in which a femoral ring spacer filled with an rhBMP-2-soaked sponge was retrieved from a woman who had undergone a combined anterior and posterior spinal reconstruction but had early dislodgment of the interbody graft. To our knowledge, this is the first report of retrieval and analysis of an rhBMP-2-soaked collagen sponge in …

Aging spine is prone to osteoporotic fractures that can cause considerable morbidity due to pain and deformity. Most osteoporotic vertebral compression fractures will respond to non-operative therapy that includes pain medications and bracing. For those who are resistant to conservative therapy, vertebroplasty or kyphoplasty can be a viable option. Most recent studies show 88%-96% satisfaction in pain reduction with vertebroplasty. Several studies have also shown similar satisfaction with kyphoplasty. Because these procedures are relatively new, however, indications, long-term effects, and intra-operative and peri-operative complications are not yet fully understood. Reported complications from both vertebroplasty and kyphoplasty are low, but can include increased pain, radiculopathy, spinal cord compression, pulmonary embolism, infection, and rib fractures. In this review, we summarize the current understanding of anatomy, biomechanics, indications, complications, techniques, and new technologies of vertebroplasty and kyphoplasty.

STUDY DESIGN A critical review of available and emerging nucleus pulposus replacement implants. OBJECTIVES To review the biomechanics, design, and clinical data of currently available and developing nucleus pulposus replacement technologies. SUMMARY OF BACKGROUND DATA The interest in minimally invasive treatment of degenerative disc disease has grown as the technology for intervertebral motion-sparing devices continues to improve. Replacement of nucleus pulposus without anular obliteration represents a tempting alternative to spinal fusion procedures. The aim in nucleus pulposus replacement is to slow adjacent level degeneration, restore normal loads to the diseased level, and restore segmental spinal biomechanics. METHODS A literature review of currently available biomaterials, biomechanics, and available preclinical and clinical data on nucleus pulposus replacement implants. RESULTS New synthetic biomaterials have recently been developed to closely mimic native biomechanics during compressive loading cycles of the intervertebral disc. This, in conjunction with improved understanding of global spine biomechanics, has allowed the development of novel nucleus replacement implants. These implants are currently at different stages of preclinical and clinical investigations. CONCLUSIONS Although some of the newly designed prosthesis have shown some promising results in preclinical studies, rigorous short- and long-term clinical evaluations will be critical in evaluating their true efficacy.

Nonfusion technology in spine surgery may improve outcomes by reducing surgical morbidity and the incidence of adjacent level degeneration; however, new technologies also introduce new short- and long-term complications. There is currently no evidence that nonfusion implants are superior to fusion in mid- to long-term follow-up. Understanding the potential risks and benefits of nonfusion technology is essential for spine surgeons and their patients. This article reviews the current evidence relating to the potential risks and benefits of nonfusion technology in spine surgery.

Dysphagia is a relatively common complication of anterior cervical spine surgery. Smoking has not been definitively assessed as a risk factor for dysphagia. This study examined risk factors for dysphagia, including smoking and pain severity. The authors performed a cross-sectional cohort study of 100 patients who underwent anterior cervical diskectomy and fusion (ACDF). Dysphagia was assessed with the Yoo-Bazaz questionnaire. Clinical notes were reviewed for demographic information, diagnosis, preoperative pain severity, preoperative smoking status, and operative details. The dysphagia questionnaire was administered via telephone. The rate of dysphagia at an average of 2.75 years (33 months) was 26%. Rare and mild dysphagia were reported by 2% and 7% of patients, respectively. Moderate dysphagia was reported by 12% patients, and severe dysphagia was reported by 5% of patients. Smokers were more likely to report dysphagia symptoms, and their dysphagia scores were more severe than those in nonsmokers (1.17 vs 0.54; P =.02). Patients undergoing revision surgery (n=7) had dysphagia at a rate of 71% compared with 23% of patients undergoing primary surgery ( P Orthopedics. 2015; 38(4):e319–e323.]

STUDY DESIGN Patient survey. OBJECTIVE To evaluate patient perspective on surgeons as consultants for industry and medical device manufacturers. SUMMARY OF BACKGROUND DATA Relationships between surgeons and medical device manufacturers are becoming increasingly common. Little is known, however, about how patients perceive these relationships. METHODS Patients in the waiting area of an orthopedic surgery clinic were given a simple 1-page, 8-question anonymous questionnaire. Their responses were tabulated and analyzed for 3 variables: gender, age, and education level. RESULTS A total of 245 patients completed the questionnaire. An overwhelming majority (94.3%) believed that surgeon-industry relationship is beneficial to patients, and a majority (66.5%) of patients thought that physicians should be compensated for this role. Women were more likely than men to want this relationship to be regulated by physicians instead of the government or hospitals. Patients older than 55 years were less likely to be in favor of physicians being compensated than younger patients. The more educated the patient, the less likely he/she was in favor of allowing physicians to regulate physician-industry relationship. CONCLUSION Patients support surgeons in the role of consultants for industry. Gender, age, and education level influence the way that patients perceive this issue.

Objective To assess the general use of all non-steroidal anti-inflammatory drugs (NSAID) and their relation to upper gastrointestinal bleeding in view of National Institute for Clinical Excellence guidelines published in July 2001 in the UK. Methods Cross sectional study on all patients who were referred for endoscopy for suspected upper gastrointestinal bleeding in six hospitals in Yorkshire region of the UK. Results One hundred and sixty three patients presented for endoscopy for suspected upper gastrointestinal bleeding, 43 patients were taking at least one ulcerogenic drug, and 120 were not. The mean age difference between these two groups was eight years (p Conclusions Elderly patients are being inappropriately prescribed conventional NSAIDs. NSAIDs with or without aspirin use are still associated with a significant risk of upper gastrointestinal bleeding in the era of cyclo-oxygenase 2 selective agents. Substitution with cyclo-oxygenase 2 selective NSAIDs is not without risk of upper gastrointestinal bleeding.

Spine stabilization after C3–C7 laminectomy can be accomplished with many instrumentation options. A hybrid construct using lateral mass screws from C3 to C5 and pedicle screws at C7 can potentially maximize strength and solve the spatial constraints introduced by the placement of C6 lateral mass screws and C7 pedicle screws. Seven cadaveric cervical spines from C2 to T2 were potted in a custom testing apparatus. Differential variable reluctance transducers were placed on C6 and C7 to measure linear displacement. Specimens were loaded in flexion, extension, lateral bending, and axial torque at 1.5 Nm. A wide laminectomy was then performed, and specimens were randomized to first receive either the bilateral C3–C7 lateral mass screw construct or a hybrid construct with C3–C5 lateral mass screws and C7 pedicle screws. All specimens were tested with both constructs. Normalized deformation (mean±SD) for the lateral mass screw vs the hybrid pedicle screw constructs in the sagittal plane was 7.46%±5.48% vs 5.68%±3.67%, respectively ( P =.237). Coronal deformation for lateral mass screw vs the hybrid pedicle screw constructs was 19.2%±10.9% vs 13.6%±9.53% ( P =.237). Axial rotation deformation for lateral mass vs pedical screw constructs was 85.9%±83.3% vs 74.7%±58.1%, respectively ( P =.868). Despite data reported in the literature indicating a higher pullout strength of pedicle screws and improved strength of hybrid pedicle screw constructs compared with lateral mass screw constructs, a hybrid construct taking spatial constraints and increased danger of pedicle screw placement above C7 into account showed no improvement in motion compared with a lateral mass screw construct.

STUDY DESIGN Retrospective case-control study/economic analysis. OBJECTIVE To determine the treatment times required for isolated lumbar decompressions and for combined decompression and instrumented fusion procedures to compare the relative reimbursements for each type of operation as a function of time expenditure by the surgeon. SUMMARY OF BACKGROUND DATA Under current Medicare fee schedules, the payment for a fusion procedure is higher than of an isolated decompression. It has been recently suggested in the lay press that the greater reimbursement for a lumbar arthrodesis may inappropriately influence the manner in which surgeons elect to treat lumbar degenerative conditions, resulting in what they believe to be a substantial number of unnecessary spinal fusions. METHODS A consecutive series of 50 single-level decompression cases performed by single surgeon were retrospectively analyzed and compared with an equivalent cohort of subjects who underwent single-level decompression and instrumented posterolateral fusion with autogenous iliac crest bone grafting. The operative reports, office charts, and billing records were reviewed to determine the total clinical time invested by the surgeon and the Medicare reimbursement for each surgery. RESULTS Relative to the corresponding values of the decompression group, combined decompression and fusion procedures were associated with a longer mean surgical time (134.6 min vs. 47.3 min, P