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Background: Intraoperative neuromonitoring (IONM) is frequently used during spine surgery to mitigate the risk of neurological injuries. Yet, its role in anterior cervical spine surgery remains controversial. Without consensus on which anterior cervical spine surgeries would benefit the most from IONM, there is a lack of standardized guidelines for its use in such procedures. Purpose: We sought to assess the alerts generated by each IONM modality for 4 commonly performed anterior cervical spinal surgeries: anterior cervical diskectomy and fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), cervical disk replacement (CDR), or anterior diskectomy. In doing so, we sought to determine which IONM modalities (electromyography [EMG], motor evoked potentials [MEP], and somatosensory evoked potentials [SSEP]) are associated with alert status when accounting for procedure characteristics (number of levels, operative level). Methods: We conducted a retrospective review of IONM data collected by Accurate Neuromonitoring, LLC, a company that supports spine surgeries conducted by 400 surgeons in 8 states, in an internally managed database from December 2009 to September 2018. The database was queried for patients who underwent ACCF, ACDF, anterior CDR, or anterior diskectomy in which at least 1 IONM modality was used. The IONM modalities and incidence of alerts were collected for each procedure. The search identified 8854 patients (average age, 50.6 years) who underwent ACCF (n = 209), ACDF (n = 8006), CDR (n = 423), and anterior diskectomy (n = 216) with at least 1 IONM modality. Results: Electromyography was used in 81.3% (n = 7203) of cases, MEP in 64.8% (n = 5735) of cases, and SSEP in 99.9% (n = 8844) of cases. Alerts were seen in 9.3% (n = 671), 0.5% (n = 30), and 2.7% (n = 241) of cases using EMG, MEP and SSEP, respectively. In ACDF, a significant difference was seen in EMG alerts based on the number of spinal levels involved, with 1-level ACDF (6.9%, n = 202) having a lower rate of alerts than 2-level (10.0%, n = 272), 3-level (15.2%, n = 104), and 4-level (23.4%, n = 15). Likewise, 2-level ACDF had a lower rate of alerts than 3-level and 4-level ACDF. A significant difference by operative level was noted in EMG use for single-level ACDF, with C2-C3 having a lower rate of use than other levels. Conclusions: This retrospective review of anterior cervical spinal surgeries performed with at least 1 IONM modality found that SSEP had the highest rate of use across procedure types, whereas MEP had the highest rate of nonuse. Future studies should focus on determining the most useful IONM modalities by procedure type and further explore the benefit of multimodal IONM in spine surgery.

Retrospective review.To analyze if shoulder balance continues to change in the postoperative period in patients undergoing selective lumbar fusion for adult spinal deformity (ASD), and secondarily, analyze if shoulder balance correlates with health-related quality of life (HRQOL) outcomes.Shoulder balance in patients with ASD is poorly understood and has largely been extrapolated from adolescent scoliosis literature.Adult patients who underwent selective lumbar fusion (upper instrumented vertebra: Τ9-Τ12, lower instrumented vertebra: L4-Pelvis) for thoracolumbar or lumbar scoliosis (cobb angle30°) or sagittal plane deformity with thoracic compensatory curves (cobb angle10°) were identified. The clavicular angle (CA) was used to quantify shoulder balance. Shoulder balance was categorized into three groups postoperatively (balanced: CA2°, mild imbalance: CA 2°-4°, severe imbalance: CA4°). The average CA and proportion of patients in each shoulder balance group were compared at each postoperative period. Patients with 1-year postoperative HRQOL scores were identified.Eighty-six patients were included. The preoperative CA was 2.7 ± 2.3° and did not significantly change at discharge (2.9 ± 2.4°), 6-weeks (2.5 ± 2.1°), 6-months (2.4 ± 2.2°), 1-year (2.4 ± 2.5°), or 2-years (2.3 ± 1.5°) postoperatively. The proportion of patients in each shoulder balance group did not significantly change from discharge to 6-weeks, 6-months, 1-year or 2-years postoperatively (P 0.1). At 1-year follow-up, the CA demonstrated no significant correlation with Oswestry Disability Index, Scoliosis Research Society (SRS)-22 score, or SRS-22 subscores. There was no significant association between shoulder balance group and Oswestry Disability Index, SRS-22 score, or SRS-22 subscores.In patients with ASD undergoing selective lumbar fusion, shoulder balance did not change over the postoperative period. From a functional standpoint, shoulder balance demonstrated no correlation with HRQOL scores. In patients undergoing selective lumbar fusion for ASD, shoulder balance may not spontaneously correct over the postoperative period, but this may not be of functional consequence.Level of Evidence: 4.

OBJECTIVE To evaluate outcomes of cervical disc replacement (CDR) in patients with nonlordotic alignment. METHODS Patients who underwent CDR were retrospectively reviewed and divided into 3 cohorts: (1) neutral/lordotic segmental and C2-7 Cobb angle (L), (2) nonlordotic segmental Cobb angle, lordotic C2-7 Cobb angle (NL-S), and (3) nonlordotic segmental and C2-7 Cobb angle (NL-SC). Radiographic and patient-reported outcomes (PROMs) were compared. RESULTS One-hundred five patients were included (L: 37, NL-S: 30, NL-SC: 38). A significant gain in segmental lordosis was seen in all cohorts at < 6 months (L: -1.90° [p = 0.007]; NL-S: -5.16° [p < 0.0001]; NL-SC: -6.00° [p < 0.0001]) and ≥ 6 months (L: -2.07° [p = 0.031; NL-S: -6.04° [p < 0.0001]; NL-SC: -6.74° [p < 0.0001]), with greater lordosis generated in preoperatively nonlordotic cohorts (p < 0.0001). C2-7 lordosis improved in the preoperatively nonlordotic cohort (NL-SC: 8.04°) at follow-up of < 6 months (-4.15°, p = 0.003) and ≥ 6 months (-6.40°, p = 0.003), but not enough to create lordotic alignment (< 6 months: 3.89°; ≥ 6 months: 4.06°). All cohorts showed improvement in Neck Disability Index, visual analogue scale (VAS) neck, and VAS arm, without significant difference among groups in the amount of improvement ( ≥ 6-month PROMs follow-up = 69%). CONCLUSION In patients without major kyphotic deformity, CDR has the potential to generate and maintain lordosis and improve PROMs in the short-term, and can be an effective treatment option for patients with nonlordotic alignment.

Retrospective study of a multicenter Adult Spinal Deformity (ASD) Database.To investigate the change in Pelvic tilt (PT) imparted by regional changes in lumbar lordosis at 2-year minimum follow up.The distribution of lumbar lordosis between L1-4 and L4-S1 is known to vary based on pelvic incidence (PI). However, the extent to which regional changes effect PT is not clearly elucidated. This information can be useful for ASD surgical planning.Operative patients from a multicenter ASD database were included with Lowest Instrumented Vertebrae (LIV) S1/Ilium,5 levels of fusion, Proximal Junction Kyphosis (PJK) angle 20, and5 degrees of change in lumbar lordosis from L4-S1 and L1-4. Radiographic analysis was performed evaluating Thoracic Kyphosis (TK), T10-L2 kyphosis (TL), L1-S1 lordosis (LL), L4-S1 lordosis, L1-4 lordosis, sagittal vertical axis (SVA) and PI-LL from preoperative to postoperative, and change at 2-years follow-up. Stepwise regression analysis was performed in order to determine the relationship between PT and the above radiographic parameters. Health-related quality of life (HRQOL) outcomes were also compared between preoperative and postoperative timepoints at 2 years.103 patients met inclusion for the study. There was improvement in all the radiographic parameters and HRQOLs at 2 years follow-up (p 0.01). Stepwise regression model showed an inverse relationship between PT and LL change (r = 0.71, p 0.01). Regionally, an increase in 10 degrees from L4-S1 correlated with a 2.4 degree decrease in PT (p 0.01), while an increase in 10 degrees from L1-4 resulted in a 1.6 degree decrease in PT (p 0.01).In the surgical planning for ASD, our data demonstrated significant correlational difference between corrections in the upper (L1-4) and lower (L4-S1) lumbar spine and PT changes. These calculations can be useful in planning sagittal plane corrections for ASD.

Background No consensus exists regarding postoperative splinting position following volar plate fixation of distal radius fractures. Purpose The purpose of this study was to determine whether immobilization in supination would result in superior outcomes compared with no restriction of forearm range of motion. Patients and Methods All patients >18 years of age with distal radius fractures indicated for volar plate fixation were eligible. Exclusion criteria were open fracture and concomitant injury to, or functional deficit of, either upper extremity. Patients were randomized to immobilization in (1) maximal supination with a sugar-tong splint or (2) no restriction of supination with a volar splint. Patient-Rated Wrist Evaluation (PRWE), Disabilities of the Arm, Shoulder, and Hand (DASH) score, and visual analog scale (VAS) score; wrist range of motion; and grip strength were recorded at 2 and 6 weeks postoperatively. A Student's t-test was used to compare mean values of all outcome measures at each time point. Results A total of 46 patients enrolled in the study; 28 were immobilized with a volar splint and 18 were immobilized with a sugar-tong splint. Six-week follow-up data were obtained for 32 patients. There was no significant difference in PRWE, DASH, and VAS scores; or range of motion; or grip strength between the two groups postoperatively. Conclusion Range of motion, grip strength, and patient-rated outcome measures were similar regardless of postoperative immobilization technique in patients with a distal radius fractures stabilized with a volar plate. Surgeons can elect to use the standard-of-care postoperative immobilization modality of their preference following volar plate fixation without compromising short-term return to function. Level of Evidence This is a Level II, therapeutic study.

The purpose of this study was to (1) Determine the effect of computed tomography (CT) on identification of fractures involving the posterior malleolus, (2) determine its effect on operative indications, and (3) determine its effect on the overall operative plan.Patients with ankle fractures involving the posterior malleolus were identified. Only injuries with complete preoperative plain radiographs and a CT scan were included. Spiral tibia fractures and pilon variants were excluded. The plain radiographs were deidentified, randomized, and presented to 3 orthopedic surgeons. They were asked 3 questions: (1) Is this fracture simple or complex? (2) Does the injury require direct visualization and reduction? and (3) How would you position the patient and approach the fracture? The same process was repeated for the CT scans. A total of 376 posterior malleolus injuries were identified and 25 met the inclusion criteria.A complex fracture pattern was identified on 44% of plain radiographs and 56% of CT scans. The surgeons chose to operate in 84% of cases based on plain radiographs and 92% of cases based on CT scan. The observers changed their operative approach or positioning 44% of the time after reviewing CT images. The interobserver and intraobserver correlation coefficients were moderate.The use of CT scan changed operative positioning and approach in 44% of cases. There was no significant change in characterization or operative indications when comparing plain radiographs to CT scan. CT scan may be a valuable tool in the management of ankle fractures involving the posterior malleolus.Diagnostic Level III, comparative series.

Long head of the biceps tendon (LHBT) tenodesis is predominantly performed for 2 reasons: anterior shoulder pain (ASP) or structural reasons (partial tear, dislocation).Between 2006 and 2014, all cases of primary LHBT tenodesis performed at an integrated health care system were retrospectively reviewed. Complications were analyzed by tenodesis location (below or out of the groove [OOG] vs leaving tendon in the groove [ITG]), fixation method (soft tissue vs implant), and indication (preoperative ASP vs structural).Among 1526 shoulders, persistent ASP did not differ by fixation method (11.0% for implant vs 12.8% for soft tissue, P = .550) or location (10.8% for OOG vs 12.9% for ITG, P = .472). Soft-tissue tenodesis cases had more frequent new-onset ASP (11.9% vs 2.6%, P .001) and subjective weakness (8.50% vs 3.92%, P .001) but less frequent revisions (0% vs 1.19%, P = .03) than implant tenodesis cases. No difference was found between ITG and OOG for persistent ASP (12.9% vs 10.8%, P = .550), new-onset ASP (6.5% vs 2.8%, P = .339), cramping (1.70% vs 2.31%, P = .737), deformity (4.72% vs 4.62%, P = .532), or subjective weakness (6.23% vs 4.32%, P = .334), but ITG cases had more revisions (1.51% vs 0.60%, P = .001). Among implant tenodesis cases, 1 shoulder (0.085%) sustained a fracture.The overall complication rate of LHBT tenodesis was low. Of the shoulders, 10.8% to 12.9% continued to have ASP, regardless of whether the LHBT was left ITG. Soft-tissue tenodesis cases had higher rates of new-onset ASP and subjective weakness. No significant difference for tenodesis ITG or OOG was found in biceps-related complications.