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Study design Retrospective review of prospectively collected data. Objective To determine if the addition of L5-S1 interbody support in long fusion deformity constructs is associated with superior long-term clinical and radiographic outcomes. To compare the 5-year clinical and radiographic outcomes and complications between long fusion constructs with L5-S1 interbody support vs. posterolateral fusion (PLF) alone. Summary of background data Cadaveric biomechanical studies have suggested that an interbody fusion at L5-S1 is beneficial in long fusion constructs with sacropelvic fixation. However, there is limited data reflecting the superiority of interbody support augmentation in optimizing arthrodesis and deformity correction relative to PLF alone. Methods Eighty-eight consecutive adults with spinal deformity who underwent at minimum T11-pelvis posterior pedicle screw instrumentation with 5-year follow-up were included. Two cohorts were compared based on technique used at the lumbosacral junction (L5-S1): 1) No interbody (PLF; n = 23), or 2) Interbody support at L5-S1 (IB; n = 65). Radiographic measurements and clinical outcome measures were compared at multiple time points. Complications were recorded and compared. Results No differences in baseline patient characteristics between cohorts. One nonunion occurred at L5-S1 in the PLF group (p = 0.091). Initial postop sagittal alignment (SVA) was better in the IB group (PLF: 6.46 cm, IB:2.48 cm, p = 0.007), however, this was not maintained over long-term follow-up. No significant differences in proximal junctional kyphosis (PJK) (PLF:7/23, IB:9/65, p = 0.076). Proximal junctional failure (PJF) was more frequent in the PLF group (PLF:6/23, IB:6/65, p = 0.043). No significant differences in complications were found. Both cohorts had improvement from baseline pain and functional scores. Conclusion There is no absolute long-term advantage for lumbar interbody support in adult spinal deformity patients undergoing spinal arthrodesis to the pelvis.Level of Evidence: 3.

Background: To analyze gender differences regarding the recovery experience (pain, function, complications) after spinal arthrodesis surgery. Methods: Pre-operative and post-operative gender-based differences in patient-reported outcomes for open posterior spinal arthrodesis at 6 weeks, 3 months, 6 months, and 1 year were studied, including age, comorbidities, body mass index (BMI), diagnosis, number of vertebrae fused, type of surgery, primary vs. revision surgery, and complications. Statistical analysis included the use of Student’s t-test, Chi square, linear regression, Mann–Whitney U test, and Spearman’s rho. Results: Primary or revision posterior arthrodesis was performed on 1931 consecutive adults (1219 females, 712 males) for deformity and degenerative pathologies. At surgery, females were older than males (61.7 years vs. 59.7 years, p &lt, 0.01), had slightly more comorbidities (1.75 vs. 1.5, p &lt, 0.01), and were more likely to undergo deformity correction (38% vs. 22%, p &lt, 0.01). Females described more pre-op pain (female VAS = 6.54 vs. male VAS = 6.41, p &lt, 0.01) and lower pre-op function (female ODI = 49.73 vs. male ODI = 46.52, p &lt, 0.01). By 3 months post-op, there was no significant gender difference in VAS or ODI scores. Similar pain and function scores between males and females continued through 6 months and 12 months. Conclusion: Although females have more pain and dysfunction before undergoing spinal surgery, the differences in these values do not reach the Minimum Clinically Important Difference (MCID). Post-operatively, there is no difference in pain and function scores among males and females at 3, 6, and 12 months.

This research monograph consists of 17 papers under the framework of contemporary economic and business issues which we can structure into several main research fields. These fields relate to the regulation of economic and business activities, especially in the context of digitalization processes, fiscal and monetary issues, dealing with the impact of digitalization and COVID19 pandemics on traditional academic and business debates, as well as on innovation processes in both government and the corporate sector. We can borrow the phrase from one of our papers and confirm that the papers presented show that the innovative market and digital society, as the new global development and technology paradigm of the modern world, together with its capabilities and standards, has changed the character of entrepreneurship and the state/government in terms of their new interactions. Thus, the contributions from the research monograph are made more urgent by the main objective of introspection of the traditional economic and business sectors and activities under the prism of digital transformation. The researchers were particularly interested in the impact of the COVID19 pandemic on the economic and business sectors. Although the conference was held in the midst of the pandemics, researchers were able to present valuable studies showing the extent of the threat posed by COVID 19 to the public health and economic outcomes of EU citizens. Significant pressure was placed on member state spending, particularly in countries with lower fiscal capacity, resulting in a severe temporary deterioration in the fiscal deficit and public debt. It is also noted that the crisis COVID -19 will have an uneven impact on member states and could deepen their divergence. Therefore, new and creative fiscal policies to support investment in digital transformation, green transition and innovation are of utmost importance. This monograph provides some guidance.

Study Design: Retrospective review. Objectives: (1) Identify the 90-day rate of readmission following revision lumbar fusion, (2) identify independent risk factors associated with increased rates of readmission within 90 days, (3) and identify the hospital costs associated with revision lumbar fusion and subsequent readmission within 90 days. Methods: Utilizing 2014 data from the Nationwide Readmissions Database, patients undergoing elective revision lumbar fusion were identified. With this sample, multivariate logistic regression was utilized to identify independent predictors of readmission within 90 days. An analysis of total hospital costs was also conducted. Results: In 2014, an estimated 14 378 patients underwent elective revision lumbar fusion. The readmission rate at 90 days was 3.1% (n = 446). Diabetes with chronic complications was the only comorbidity found to carry significantly increased odds of readmission. Surgical complications such as deep venous thrombosis, surgical wound disruption, hematoma, and pneumonia (experienced during the index admission) were also independent predictors of readmission. Anterior approaches were associated with increased odds of readmission. The most common related diagnoses on readmission were hardware issues, postoperative infection, and disc herniation. Readmissions were associated with an average of $96 152 in increased hospital costs per patient compared with those not readmitted. Conclusion: Relevant patient comorbidities and surgical complications were associated with increased readmission within 90 days. Readmission within 90 days was associated with significant increases in hospital costs.

Study design Secondary analysis of a large administrative database. Objective The objectives of this study are to: 1) identify the incidence and cause of 90-day readmissions following primary elective lumbar spine surgery, 2) offer insight into potential risk factors that contribute to these readmissions, and 3) quantify the cost associated with these readmissions. Summary of background data As bundled-payment models for the reimbursement of surgical services become more popular in spine, the focus is shifting toward long-term patient outcomes in the context of 90-day episodes of care. With limited data available on national 90-day readmission statistics available, we hope to provide evidence that will aid in the development of more cost-effective perioperative care models. Methods Using ICD-9 coding, we identified all patients 18 years of age and older in the 2014 Nationwide Readmissions Database (NRD) who underwent an elective, inpatient, primary lumbar spine surgery. Using multivariate logistic regression, we identified independent predictors of 90-day readmission while controlling for a multitude of confounding variables and completed a comparative cost analysis. Results We identified 169,788 patients who underwent a primary lumbar spine procedure. In total 4268 (2.5%) were readmitted within 90 days. There was no difference in comorbidity burden between cohorts (readmitted vs. not readmitted) as quantified by the Elixhauser Comorbidity index. Independent predictors of increased odds of 90-day readmission were: anemia, uncomplicated diabetes and diabetes with chronic complications, surgical wound disruption and acute myocardial infarction at the time of the index admission, self-pay status, and an anterior surgical approach. Implant complications were identified as the primary related cause of readmission. These readmissions were associated with a significant cost increase. Conclusion There are clearly identifiable risk factors that increase the odds of hospital readmission within 90 days of primary lumbar spine surgery. An overall 90-day readmission rate of 2.5%, while relatively low, carries significantly increased cost to both the patient and hospital. Level of evidence 3.

Study Design: Retrospective comparative analysis of prospective cohort. Objective: To determine whether sacroiliac (SI) screw fixation ipsilateral to hand dominance compared to bilateral fixation impacts personal hygiene (wiping) after toileting. Methods: Inclusion criteria were adult spinal deformity (ASD) patients with long arthrodesis (≥T12-pelvis) who had undergone primary unilateral or bilateral SI fixation with a minimum of 2-years-follow-up. Results: 117 consecutive patients were included and separated into 2 groups: bilateral SI fixation (BL, n = 61) and unilateral SI fixation (UNI, n = 56), with no difference in age. Of UNI patients, 10.7% (6) performed personal hygiene with a different hand after surgery, compared to 6.6% (4) of patients who received BL fixation ( P = 0.422). All UNI patients who switched hands were right-hand dominant, and 5/6 received right-sided fixation. There was no statistical difference found between number of levels fused (11 levels) and changes in personal hygiene habits. Over a third of patients from both groups had difficulty performing personal hygiene after fusion (UNI = 39.3% BL = 36.1%, P = 0.719). Conclusion: SI screws increase the difficulty of performing personal hygiene; yet, the side of unilateral screws does not significantly change personal hygiene habits when compared to bilateral screw placement. Moreover, the length of the construct does not have a significant impact on ability to perform personal hygiene, cause changes in habits, or require the assistance of another individual. However, among our sample of individuals, bilateral fixation did result in a higher rate of revision instrumentation.

Background. Teratomas in the pediatric population are most commonly found in the sacrococcygeal region. Pediatric intraspinal teratomas, however, are an exceedingly rare central nervous system (CNS) neoplasm. The clinical presentation of these intraspinal neoplasms can vary significantly and thus can be difficult to identify in infants less than one year of age where verbal expression and motor development are still lacking. Case Description. A 7-month-old, previously healthy male presented with a thoracic scoliosis and an asymptomatic right midupper thoracic spinal prominence present since birth. MRI revealed an extensive heterogenous mass in the right epidural space from T5-T6 and the right paravertebral space, resulting in severe spinal stenosis. Outcome. Complete resection of the tumor, including a three-level neurotomy, was achieved by posterior decompression/laminectomy. The final tumor was consistent with a mature teratoma. The surgical resection was performed without any immediate complications. Conclusions. Extramedullary epidural teratomas are exceptionally rare tumors in the pediatric population. Clinical presentation can be ambiguous, particularly in an infant. MRI was useful in suggesting a teratoma as a potential diagnosis and for postoperative surveillance for recurrence. However, histopathological analysis remains the gold standard for definitive diagnosis. Surgical resection is the mainstay of treatment, especially in the setting of cord compression and progressive loss of motor function. Close follow-up is crucial to monitor for progressive spinal deformity or recurrence.

Introduction State legalization and widespread marketing efforts have increased the accessibility and consumption of off-label, non-FDA-approved, cannabinoid (CBD) products. Although clinical evidence is largely absent for the treatment of musculoskeletal pain, patients are experimenting with these products in efforts to relieve joint pain. Assessment of the prevalence, perceived efficacy compared with other nonsurgical modalities, and usage patterns is warranted. The purpose of this study was to report the prevalence and perceived self-efficacy of CBD products in patients with symptomatic hip and/or knee osteoarthritis (OA). Methods Two-hundred consecutive patients presenting with painful hip or knee OA were surveyed at their initial evaluation at a large academic center. Using Single Assessment Numeric Evaluation (SANE) scores, survey questions assessed perceived pain and effectiveness of CBD products, in addition to other nonsurgical treatment modalities. Chart review provided demographic factors. Descriptive statistics were used to characterize the data. Results Of the 200 patients (80 hip OA, 108 knee OA, and 12 both), 66% were female, and average age was 67 years (range 36 to 89 years). Twenty-four percent (48/200) of patients endorsed use of CBD products before their presentation. The average presenting SANE score (range 0 to 100) for non-CBD users was 50.8 compared with 41.3 among CBD users (P = 0.012). Sixty percent of patients learned about CBD through friends, and 67% purchased CBD directly from a dispensary. Oral tinctures (43%) and topical applications (36%) were the most commonly used forms. In addition, 8% of participants in this study had tried marijuana for their pain. Conclusion A 24% incidence of CBD usage was found among patients presenting with hip or knee OA. No significant perceived benefit of CBD use seems to exist compared with its nonuse, as patients who used CBD reported significantly worse SANE and visual analogue scale scores than nonusers at baseline. Follow-up studies are warranted to assess these findings.

BACKGROUND CONTEXT The development of proximal junctional kyphosis (PJK) is an ongoing issue in adult spinal deformity (ASD) patients following spine surgery, with an incidence reported to be as high as 61.7%. Approximately 47.4% of patients who develop PJK will require revision surgery within 6 months. Currently, there are no reports in the literature on the effects of postoperative bracing on the incidence of PJK. We sought to determine whether postoperative bracing results in decreased rates of PJK in ASD treated with open posterior instrumented fusion (PSF) greater than six levels. PURPOSE To determine whether postoperative bracing results in decreased rates of PJK in ASD patients treated with PSF greater than six levels. We hypothesized that postoperative bracing would result in lower rates of PJK. STUDY DESIGN/SETTING We performed a retrospective analysis of prospectively collected data comparing patients treated with a thoracic lumbar sacral orthosis (TLSO) postoperatively for 3 months vs no brace following PSF. PATIENT SAMPLE Consecutive cohort of ASD patients (n=112) from a single surgical spine practice who underwent PSF were included. OUTCOME MEASURES Clinical and functional outcomes assessed: Oswestry Disability Index (ODI) and Visual Analog Scale pain (VAS). Radiographic measures: spinopelvic parameters, thoracic kyphosis (T5-T12), junctional kyphosis (T10-L2), lumbar lordosis (T12-S1), sagittal and coronal alignment, and PJK angle with corresponding level. METHODS Clinical and radiographic data of 112 (78 braced and 34 non-braced) consecutive adult patients who underwent PSF (> 6 levels) for deformity correction were analyzed. Radiographic measurements were performed preoperatively and postoperatively at 6 weeks and 6 months. PJK was defined as more than 10 degrees of abnormal kyphotic angulation measured at the superior end plate of one adjacent vertebra above the upper instrumented vertebra (UIV), to the inferior endplate of the UIV. Chi-square test and ANCOVA were used to analyze data. Statistical significance was set at p≤0.05. RESULTS The baseline clinical and radiographic demographics between the two cohorts were similar. The incidence of PJK was not statistically different (p=0.98) between patients who were braced (n=13/34; 38.2%) versus those not braced (n=30/78; 38.5%) postoperatively. Women had five times greater odds of developing PJK than men [OR=5.44;(95%CI =1.51-19.64)]. There were no significant differences at 6 months follow-up between the braced and not braced groups in ODI, VAS, or radiographic features, with the exception of T10-L2 thoracolumbar kyphosis, which was 3.08 versus 7.95 degrees in the braced and non-braced groups, respectively (p=0.03). CONCLUSIONS There was no statistical difference in the incidence of PJK in the braced versus non-braced groups. Interestingly, thoracolumbar kyphosis was significantly decreased in ASD patients who were braced postoperatively. Further investigation is needed to determine if postoperative bracing is protective against excessive postoperative kyphosis. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Background With increased scrutiny regarding the cost and safety of health care delivery, there is increasing interest in judicious patient selection for total joint arthroplasty (TJA) procedures. It is unknown which comorbidities incur the greatest increase in risk to the patient and cost to the system after TJA. Therefore, this study sought to characterize the association of common preoperative comorbidities with both the risk for postoperative in-hospital complications and the total hospital cost in patients undergoing TJA. Methods A retrospective cohort study was conducted using the National Inpatient Sample. All elective, unilateral, primary or revision total knee or hip arthroplasty procedures in patients aged 40-95 years from 2008 to 2012 were identified. Common preoperative comorbidities were identified with use of clinical comorbidity software. Risk of complication and cost were calculated for each comorbidity. Results A total of 4,323,045 patients were identified. Patient comorbidities increased the risk of major postoperative complications, with the highest risk associated with congestive heart failure (CHF; relative risk [RR], 4.402), valvular heart disease (VHD; RR, 3.209), and chronic obstructive pulmonary disease (COPD; RR, 2.813). Likewise, comorbidities increased overall hospital costs, with the largest additional costs associated with coagulopathy (+$3787), CHF (+$3701), and electrolyte disorders (+$3179). The cumulative number of comorbidities was associated with increased risk ( R 2 = 0.86) and cost ( R 2 = 0.90). Conclusion The findings of our study suggest that greater comorbidity burden is associated with increased risk and cost in TJA. Specifically, this article identifies the patient comorbidities that incur the greatest increase in postoperative complications (CHF, VHD, COPD) and cost (coagulopathy, CHF, electrolyte disorders) after TJA.

There is no question that the mechanical reproducibility of film technologythe photographic basis of the medium, the regularized actions of gears and shutters, as well as the repeatability of effects-had secured cinema's status by the 1920s as the visual medium of the industrial era par excellence. Photogenie, that elusive concept at the heart of early French film theory (generally considered to be the very first theory of the film as medium) was, in an important sense, an attempt to define the nature of a cinematic art around the formal and perceptual properties of a new type of mechanical reproduction-a process that produced no concrete objects or images but rather the traces of a movement that occurred between photographic frames (or afterimages, to cite one of the English definitions of the term "photogene").1 Still, lest we forget that mechanical reproduction is only one of the ways in which the cinema can be defined, consider the following incidentwhich, as far as I can tell, is not cited in any accounts of cinema and modernity. In the years immediately following World War I, French film industry journals reported regularly on a dispute that arose between the union of moviehouse owners and operators, the Syndicat des Directeurs de Cinemas, and Compagnie Parisienne de Distribution d'Electricite over the rate at which the electricity used to light the lamp in the cinematograph should be tariffed.2 At the heart of the dispute lay a distinction, which had been written into the French laws of energy distribution in the late nineteenth century, between the energy used to drive