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OBJECTIVE The objective of this paper was to determine the interobserver reliability and intraobserver reproducibility of the AO Spine Upper Cervical Injury Classification System based on surgeon experience (< 5 years, 5–10 years, 10–20 years, and > 20 years) and surgical subspecialty (orthopedic spine surgery, neurosurgery, and "other" surgery). METHODS A total of 11,601 assessments of upper cervical spine injuries were evaluated based on the AO Spine Upper Cervical Injury Classification System. Reliability and reproducibility scores were obtained twice, with a 3-week time interval. Descriptive statistics were utilized to examine the percentage of accurately classified injuries, and Pearson’s chi-square or Fisher’s exact test was used to screen for potentially relevant differences between study participants. Kappa coefficients (κ) determined the interobserver reliability and intraobserver reproducibility. RESULTS The intraobserver reproducibility was substantial for surgeon experience level (< 5 years: 0.74 vs 5–10 years: 0.69 vs 10–20 years: 0.69 vs > 20 years: 0.70) and surgical subspecialty (orthopedic spine: 0.71 vs neurosurgery: 0.69 vs other: 0.68). Furthermore, the interobserver reliability was substantial for all surgical experience groups on assessment 1 (< 5 years: 0.67 vs 5–10 years: 0.62 vs 10–20 years: 0.61 vs > 20 years: 0.62), and only surgeons with > 20 years of experience did not have substantial reliability on assessment 2 (< 5 years: 0.62 vs 5–10 years: 0.61 vs 10–20 years: 0.61 vs > 20 years: 0.59). Orthopedic spine surgeons and neurosurgeons had substantial intraobserver reproducibility on both assessment 1 (0.64 vs 0.63) and assessment 2 (0.62 vs 0.63), while other surgeons had moderate reliability on assessment 1 (0.43) and fair reliability on assessment 2 (0.36). CONCLUSIONS The international reliability and reproducibility scores for the AO Spine Upper Cervical Injury Classification System demonstrated substantial intraobserver reproducibility and interobserver reliability regardless of surgical experience and spine subspecialty. These results support the global application of this classification system.

Background Recent phase-3 clinical trials have demonstrated very encouraging results for mRNA based vaccines against COVID-19. Current FDA and manufacturer guidelines mandate intramuscular administration of these vaccines, as other administration routes may not provide the same levels of effectiveness and safety. Observing the vast amount of published media images of persons receiving their vaccines, the authors noted in many cases the injection technique involved skin bunching, raising concerns of inadequate deltoid muscle penetration and consequent lowered vaccine efficacy. Our study hypothesis was that skin bunching will increase the skin-to-muscle distance over 20 mm, the maximal distance allowing the required 5 mm muscle penetration with a 25 mm needle. Materials and methods 60 adult volunteers from our hospital staff were recruited, and using ultrasound, the skin-to-muscle distance measured in three positions: flat, skin bunching and muscle bunching. The skin-to-muscle distance difference and correlation with gender and BMI were calculated. Results Skin bunching significantly increased the skin-to-muscle distance in all subjects. In 6 (10%) subjects, this increase exceeded the 20 mm limit. Having a skin-to-deltoid distance of 20 mm or more strongly correlated with a BMI of 30 or more. Conclusions Skin bunching will prevent adequate intramuscular injection of vaccines in a small percentage of persons, but as hundreds of millions are expected to receive mRNA vaccines in the coming months, the multiplied result can have significant personal and societal consequences for millions of people globally, especially in obese populations, and therefore this practice should be strictly discouraged.

Current spine postoperative pain control protocols consider the expected pain following spine fusion surgery to correlate with surgical extent, that is, the greater the number of operated vertebrae, the greater the postoperative pain. Due to this assumption, Enhanced Recovery After Surgery (ERAS) protocols are principally applied to minimally invasive and percutaneous spine surgery and less to open extensive spine fusion operations. The aim of this study was to determine whether postoperative pain does in fact correlate with the surgical extent, potentially opening the door to non-narcotic postoperative pain protocols for this patient subset.Forty consecutive patients, undergoing open posterior spine surgery, were evaluated for postoperative pain during the first 72 after surgery. All patients were then divided into two groups according to the number of spine levels fused, and the correlation between the number of fusion levels and self-reported pain was analyzed statistically.Self-reported pain levels were not found to correlate with the extent of the spine operation.As "bigger operation" does not necessarily equate with "bigger pain," adequate postoperative pain control after extensive spine fusion surgery might be achieved without the routine use of narcotic medication, as practiced after minimally invasive and percutaneous surgery. Additional prospective randomized trials are needed to further substantiate this conclusion.

The natural history of lumbar disc herniation with radiculopathy is favorable, with 95% of patients expected to be pain-free within 6 months of onset. Despite the favorable prognosis, operative treatment is often chosen by patients unable to “ride out” the radicular episode. Prospective studies comparing surgical with non-surgical treatment have demonstrated similar long-term results. We conducted a retrospective case-series study of patients with a lumbar disc herniation and intractable radicular pain without significant neurological deficits treated with intra-venous dexamethasone. The primary outcome measure was whether the patient had undergone operative treatment within 1 year of receiving the intravenous steroid treatment. 213 patients met our inclusion criteria. 30 were lost to follow-up and 2 had died before completing 1 year of follow-up. Of the remaining 181 patients, 133 (73.48%) had not undergone surgery within 1 year of receiving intra-venous steroid treatment while 48 (26.51%) had undergone surgery. 6 (3.31%) of the patients had undergone surgery more than 1 year of receiving IV steroid treatment. Intravenous steroid treatment in our retrospective series was approximately 30% better at preventing the need for surgery than the reported outcomes of conservative treatment in randomized controlled trials previously published.

Background Pyogenic spondylodiscitis is diagnosed in recent years at higher rates due to the aging population, increased survival of chronic and immune suppressed patients, and the higher rate of invasive procedures leading to bacterial seeding or direct contamination of the disc space. Treatment guidelines encourage bacterial sampling before initiation of antibiotic therapy, and drainage of pus collections. We present our experience with percutaneous CT-guided drain insertion into the disc space itself as a one-step procedure for both culturing and subsequent continuous drainage of the infected disc space. Materials and methods We retrospectively reviewed all cases of pyogenic spondylodiscitis admitted to our spine surgery unit during the past five years and treated with CT-guided percutaneous drain insertion into the infected disc space. All patients were followed until complete resolution of the infection. Results We retrieved electronic records of 12 patients, none presenting with neurological compression symptoms. Cultures taken at the time of drain insertion were positive in 10 patients (83.3%), much higher than the reported yield for needle aspiration (14–48%) and comparable to the yield of open biopsy. In all patients complete resolution of the infection was reached, determined by clinical, laboratory, and imaging parameters. Conclusions Our retrospective case series demonstrates the feasibility and effectiveness of intra-discal CT-guided drainage of an infected disc space. The procedure does not add much burden to current practice as disc-space sampling for culture is commonly performed anyway, and adds the benefit of direct drainage of the pus at its source.

The collapse of the Syrian healthcare system during the civil war led numerous citizens to cross the Syrian-Israeli border to seek medical care.To describe the epidemiology of peripheral nerve injuries (PNIs) sustained in war, their management, and short-term outcomes.A retrospective case series study was conducted on 45 consecutive patients aged 25.7 ± 9.3 years. These patients were referred to the hand surgery unit of the department of orthopedic surgery and traumatology at Galilee Medical Center between December 2014 and June 2018. Median time between injury and presentation was 60 days. Injury pattern, additional injuries, surgical findings and management, complications, and length of hospital stay were extracted from medical records.Most injuries were blast (55.6%) followed by gunshot injuries (37.8%). There were 9 brachial plexus injuries, 9 sciatic nerve injuries, and 38 PNIs distal to the plexus: specifically 20 ulnar, 11 median, and 7 radial nerve injuries. In the latter group, neurotmesis or axonotmesis was found in 29 nerves. Coaptation was possible in 21 nerves necessitating cable grafting in 19. A tendon transfer was performed for 13 peripheral nerves, occasionally supplementing the nerve repair. The patients returned to their country after discharge, average follow-up was 53.6 ± 49.6 days.For nerve injuries sustained in war, early surgical treatment and providing adequate soft tissue conditions is recommended. Tendon transfers are useful to regain early function.

Background: Controversy still exists regarding the optimal method for post-operative skin closure in orthopedic surgery. In total knee replacement, closure with metal staples is faster but carries ...

Background Supracondylar fractures of the humerus in children are frequently managed by closed reduction and percutaneous pinning. Insertion of medial and lateral pins is more stable than lateral pinning alone, but carries an increased risk for ulnar nerve damage. This study describes the use of electrical stimulation concurrent with medial pin insertion as a monitoring technique for avoiding iatrogenic ulnar nerve injury. Methods A retrospective review was conducted on 138 children, mean age 5.6 years (SD±2.5), who were admitted to the hospital between 2007 and 2010 with uncomplicated supracondylar fractures, Gartland type II and above, and intact neurovascular presentation. The location of the ulnar nerve was identified and marked preoperatively by observing twitch contractions in response to electrical stimulation. The medial pin served as an active electrode during pin insertion, and repeated stimulation throughout the insertion process ensured no contact with the response of the ulnar nerve. After pin insertion, ulnar nerve stimulation was used again to ensure nerve continuity viability. Results All fractures were stabilized with 2 to 4 cross K-wires (size 1.6 mm), with number depending on stability of the fracture. The children were discharged home 2 days after fracture fixation, with no iatrogenic ulnar nerve injury observed in any of the children. The only postoperative complication involved 2 cases of anterior interosseus nerve neuropraxia, which resolved spontaneously after 4 to 6 months. Primary fracture healing was achieved without nonunions or delayed unions in all cases. Conclusions Ulnar nerve stimulation before and during the percutaneous pinning of supracondylar fractures in children is a simple, economical, and easy-to-implement technique that can prevent iatrogenic ulnar nerve injury. Level of evidence Level IV.

Background Internal fixation of unstable thoracolumbar spine fractures requires correction of the lacking anterior column support. This usually entails insertion of a vertebral body replacement strut through an anterior approach, or a long posterior construct spanning at least two vertebrae above and two vertebrae below the fracture. Posterior short-segment pedicle instrumentation (SSPI)—one vertebra above and below—is suitable for approximately 40% of fractures, but not for all.

Background and Objectives: Pathologic fractures due to disseminated metastases are common and often involve major long bones, where the metastasis is responsible for wide bone erosion that is equivalent to major bone loss. Stabilization of these fractures necessitates tumor excision and reconstruction of the destructive metastatic process. Methods: Massive allografts were used either as intercalary or composite grafts (allografts and regular prostheses) in 17 patients. Results: Fourteen patients could ambulate independently after surgery, and nursing of the remaining three became feasible and less painful. Conclusion: In the event of pathologic fractures due to metastatic bone diseases associated with major bone involvement, massive bone allografts offer an inexpensive, adjustable, simple solution.

Controlling cement leakage is indeed an important technical consideration when performing any type of vertebral augmentation, even though the consequences of such leakage are often more radiographic than clinical [1]. We appreciate the important technical tips provided in this letter and are certain of their efficacy. Unfortunately, two-stage cementing is not a viable option when augmenting an intact vertebra to prevent screw pullout, and other measures are needed to address this issue. Following our experience described in this article, we have slightly changed the surgical technique. Today, we use fenestrated screws through which the PMMA is injected after screw insertion, thus enabling the use of smaller volumes of cement, in a more viscous phase. Another change we have instituted is to pre-heat the PMMA to approx 50 °C, and not rely on ambient operating room temperature to cure it. Pre-heating the cement not only shortens wait times in the operating room but also changes the physical properties of the semi-cured cement, making it more viscous, and the fully-cured cement more porous and adherent [2, 3]. This is beneficial in cementing both intact and fractured vertebrae. We are currently collecting our data, but the general impression is that these measures have reduced the leakage rate considerably.