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Background: Management of scaphoid nonunions with bone loss varies substantially. Commonly, internal fixation consists of a single headless compression screw. Recently, some authors have reported on the theoretical benefits of dual-screw fixation. We hypothesized that using 2 headless compression screws would impart improved stiffness over a single-screw construct. Methods: Using a cadaveric model, we compared biomechanical characteristics of a single tapered 3.5- to 3.6-mm headless compression screw with 2 tapered 2.5- to 2.8-mm headless compression screws in a scaphoid waist nonunion model. The primary outcome measurement was construct stiffness. Secondary outcome measurements included load at 1 and 2 mm of displacement, load to failure for each specimen, and qualitative assessment of mode of failure. Results: Stiffness during load to failure was not significantly different between single- and double-screw configurations ( P = .8). Load to failure demonstrated no statistically significant difference between single- and double-screw configurations. Using a qualitative assessment, the double-screw construct maintained rotational stability more than the single-screw construct ( P = .029). Conclusions: Single- and double-screw fixation constructs in a cadaveric scaphoid nonunion model demonstrate similar construct stiffness, load to failure, and load to 1- and 2-mm displacement. Modes of failure may differ between constructs and represent an area for further study. The theoretical benefit of dual-screw fixation should be weighed against the morphologic limitations to placing 2 screws in a scaphoid nonunion.

Study Design: Literature review. Objectives: To review the evidence for surface-based navigation in minimally-invasive spine surgery (MIS), provide an outline for its workflow, and present a wide range of MIS case examples in which surface-based navigation may be advantageous. Methods: A comprehensive review of the literature and compilation of findings related to surface-based navigation in MIS was performed. Workflow and case examples utilizing surface-based navigation were described. Results: The nascent literature regarding surface-based intraoperative navigation (ION) in spine surgery is encouraging and initial studies have shown that surface-based navigation can allow for accurate pedicle screw placement and decreased operative time, fluoroscopy time, and radiation exposure when compared to traditional fluoroscopic imaging. Surface-based navigation may be particularly useful in MIS cervical and lumbar decompressions and MIS lumbar instrumentation cases. Conclusions: Overall, it is possible that surface-based ION will become a mainstay in the armamentarium of enabling technologies utilized by minimally-invasive spine surgeons, but further studies are needed assessing its accuracy, complications, and cost-effectiveness.

BACKGROUND CONTEXT Patients undergoing minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) frequently present with lower extremity neurologic symptoms with or without associated lower back pain. While symptomatic improvement of leg and back pain has been reported, the resolution of back pain when it is a predominant presenting symptom remains underreported following MI-TLIF. PURPOSE The purpose of this study was to compare clinical outcomes at 1 year of patients undergoing MI-TLIF with lower extremity neurologic symptoms with and without a significant component of back pain. STUDY DESIGN A retrospective review of prospectively collected data from a single surgeon surgical database from 2017 to 2019 was performed. PATIENT SAMPLE Fifty one patients undergoing MI-TLIF. OUTCOME MEASURES Self-reported measures included the Oswestry Disability Index (ODI), Visual analog scale back pain (VAS-back), and VAS leg pain (VAS-leg). METHODS Patients were divided into two groups: Leg Pain Predominant (patients reported greater than 50% leg pain upon presentation) and Back Pain Predominant (patients reported 50% or greater back pain). Multivariate analysis was performed to determine differences between groups based upon any significantly baseline characteristics. RESULTS Preoperative demographic and radiographic outcomes were similar between the two groups. Both groups demonstrated significant improvement in ODI, VAS-Back and VAS-leg at 1-year postoperatively. On multivariate analysis, there were differences in ODI at 1-year, 1-year back pain, and 1-year leg pain between groups with those who initially presented with leg pain having a lower ODI, VAS Back, and VAS leg. Patients who presented with predominantly leg pain were more likely to meet minimal clinically important difference (MCID) criteria for ODI and VAS-back compared to those with predominantly back pain. CONCLUSION Following MI-TLIF, patients with lower extremity neurologic symptoms with and without a significant component of back pain have improvements in back pain, leg pain, and ODI regardless of their primary presenting pain complaint; however, patients who presented with predominantly leg pain were more likely to meet MCID criteria for improvement in their back pain and ODI score.

BACKGROUND CONTEXT Recently, a single position lumbar fusion has been described in which both the anterior or lateral interbody fusion as well as posterior percutaneous pedicle screw fixation are performed in a single position. PURPOSE The purpose of this study was to present and analyze the current evidence for single position lumbar fusion. STUDY DESIGN/SETTING This is a systematic review and meta-analysis. PATIENT SAMPLE Prospective or retrospective studies published in English that assessed outcomes of single position lumbar fusion surgery for patients with lumbar degenerative disease, spondylolisthesis, or radiculopathy were included. OUTCOME MEASURES Outcome measures included operative time, estimated blood loss, hospital length of stay, X-Ray exposure time, and postoperative outcomes including leg numbness or pain, leg weakness, lumbar lordosis, and segmental lordosis. METHODS This systematic review was performed in accordance with PRISMA guidelines. Two separate meta-analyses were performed. The first compared single position (SP) surgery, both lateral and prone, to dual position or flipped (F) surgery. The second meta-analysis compared lateral single position (LSP) surgery to prone single position (PSP) surgery. Variables were included if (1) they were a mean with a reported standard deviation or (2) if they were a categorical variable. For calculating standard error of the mean, we used sample size, mean, and standard deviation. A random effects model was used. The heterogeneity among studies was assessed with a significance level of

BACKGROUND: Cervical disc arthroplasty (CDA) was originally approved by the US Food and Drug Administration (FDA) in 2007 as a motion-sparing procedure to treat cervical degenerative disc disease. Since then, promising results from randomized control trials have led to increasing popularity. However, data discussing monetary trends are limited. The aim of this study was to determine how utilization, hospital charges, and Medicare physician reimbursement for CDA have changed over time. METHODS: In this retrospective cohort study, International Classification of Diseases procedure codes were used to identify all patients who underwent CDA from 2007 to 2017 in the National Inpatient Sample database. The Physician Fee Schedule Look-up Tool from the Centers for Medicare and Medicaid Services was queried for primary CDA using current procedural terminology codes to determine Medicare physician reimbursement from 2009 to 2021. Nominal monetary values were adjusted for inflation using the Consumer Price Index and inflation-adjusted data reported in 2021 US dollars. RESULTS: A total of 33,079 weighted patients who underwent CDA were included for analysis. CDA utilization increased by 183% from 2007 to 2017, with Medicare beneficiary utilization increasing 149%. Inflation-adjusted total hospital charges for CDA increased by 22.4%. However, inflation-adjusted Medicare physician reimbursement fell by 1.20% per year, demonstrating a total decrease of 12.9%, starting at $1928 in 2009 and declining to $1679 in 2021. CONCLUSIONS: While utilization and total hospital charges for CDA continue to rise, Medicare physician reimbursement has not shown the same trend. In fact, inflation-adjusted reimbursement has seen a steady decline since FDA approval in 2007. If this trend persists, it may become unsustainable for physicians to continue offering CDA to Medicare patients. As disproportionate increases in hospital charges incentivize a transition to outpatient CDA, stricter patient selection criteria associated with outpatient procedures may create health care disparities for Medicare patients and those with higher comorbidity burden. CLINICAL RELEVANCE: This study shows the decreasing reimbursement trends for CDA, which may disproportionately affect Medicare patients and those with increased comorbidities. LEVEL OF EVIDENCE: 3.

BACKGROUND: The purpose of this review is to provide a brief history of previous attempts at developing patient screening tools and to further examine the definitions of these psychological concepts, relevance to clinical outcomes, and implications for spine surgeons during preoperative patient assessments. METHODS: A literature review was performed by 2 independent researchers to identify original manuscripts related to spine surgery and novel psychological concepts. The history of presurgical psychology screening was also studied, and definitions of frequently utilized metrics were detailed. RESULTS: Seven manuscripts were identified that utilized psychological metrics for preoperative risk assessments and correlated outcomes with these scores. The metrics most frequently used in the literature included resilience, patient activation, grit, and self-efficacy. DISCUSSION: Current literature favors resilience and patient activation as important metrics for preoperative patient screening. Available studies demonstrate significant associations between these character traits and patient outcomes. Further research is warranted to investigate the roles of preoperative psychological screening to optimize patient selection in spine surgery. CLINICAL RELEVANCE: The purpose of this review is to provide clinicians with a reference for available psychosocial screening tools and their relevance to patient selection. This review also serves to guide future research directions given the importance of this topic. LEVEL OF EVIDENCE: 4.

Retrospective cohort study.The aim was to compare clinical outcomes in patients with significant cervical spondylosis treated with cervical disc replacement (CDR) compared with anterior cervical discectomy and fusion (ACDF).As CDR utilization has increased over the past decade, recent studies have investigated the outcomes of CDR in patients with more significant spondylotic changes and demonstrated improved postoperative patient-reported outcomes (PROs). However, no prior study has investigated clinical outcomes of patients with significant spondylotic changes treated with CDR in comparison to ACDF.Patients who underwent 1-level or 2-level CDR or ACDF with significant cervical spondylosis, quantified using a validated grading scale, were identified, and prospectively collected data was retrospectively reviewed. The following PROs were analyzed: Neck Disability Index (NDI), visual analog scale-Neck, visual analog scale-Arm, and PROMIS Physical Function (PROMIS-PF) Computer Adaptive Test Score. Demographic, operative, and radiographic variables, and achievement of minimum clinically important difference (MCID) for each PRO were compared between the 2 groups.A total of 66 patients were included in the present study, of which 35 (53%) were treated with CDR and 31 (47%) with ACDF. The preoperative cervical spondylotic grade was similar between the 2 groups (1.8 vs. 2.2, P=0.27). At final follow-up, there was no significant difference in the absolute value for each PRO between the 2 groups (P0.19) and both groups demonstrated significant improvement in each PRO compared with preoperative values (P0.01). There was no significant difference in the percentage of patients achieving the MCID for each PRO when comparing CDR to ACDF (P0.09).A similar percentage of patients with significant degenerative cervical spondylosis achieved the MCID across multiple PROs when treated with CDR or ACDF. Patients in both treatment groups demonstrated significant improvement in all PROs assessed when compared with preoperative values.Level III.

Retrospective cohort study.The aim of this study was to examine sagittal alignment over time in adult spinal deformity (ASD) and to understand whether these changes vary by choice of upper instrumented vertebra (UIV).Recent ASD literature has focused on specific alignment goals. Less is known about how sagittal parameters evolve over time after surgical correction and whether these changes differ by choice of UIV.This was a retrospective review of ASD patients from a single institution. Routine 36″ sagittal x-rays were obtained preoperatively, before hospital discharge, and at 6 months, 1 year, and 2 years and sagittal parameters were measured. Patients with UIV T6 and above were classified as upper thoracic (UT) and T7 and below as lower thoracic (LT).A total of 102 patients with mean age 66.0 years (±7.7) were included in the analysis (49 UT, 53 LT). All sagittal and coronal alignment parameters demonstrated significant improvement from preoperatively to any postoperative time point. Although multiple parameters maintained correction over time, others (TK, TPA, and PT) demonstrated significant increase from discharge to 2 years postoperatively, with changes occurring relatively early after surgery, whereas overall global alignment was maintained. Both UT/LT groups demonstrated significantly greater TK from preoperatively to discharge to 6 months (P 0.05), stabilizing at that time point out to 2 years, whereas TLK preferentially increased in the LT group. There was significant improvement in sagittal vertical axis after surgery, which was maintained out to 2years of follow-up (P 0.05).Our data suggest that although several key parameters are maintained over time out to 2years postopera- tively, TK tends to worsen over time for all patients, whereas TLK preferentially increases in the LT group. Nevertheless, despite these trends, compensatory changes are seen in PT such that global alignment is relatively maintained.Level of Evidence: 3.

Over the past decade, several review articles have evaluated the techniques and outcomes of robotics vs traditional methods in spine surgery. Recently, robot-assisted pedicle screw placement has emerged, representing an important milestone in the evolution of spine surgery. In the present article, the authors aim to provide the historical context regarding the use and growth of spinal robotics through the lens of the Industrial Revolution and the personal computer revolution. While the former provides insight into the current implications of robotics in spine surgery, the latter predicts future steps in this arena.

Study Design Retrospective Cohort Study Objectives Cervical radiculopathy and peripheral entrapment neuropathies often have overlapping symptoms that are difficult to distinguish on physical examination. Small-scale studies have attempted to report the incidence of this phenomenon, often called double crush syndrome (DCS), with varying results. The present study aims to determine the incidence of concomitant cervical radiculopathy and peripheral nerve compression and to determine if the DCS hypothesis, which states that compression of a nerve at one site leaves it more susceptible to compression at another, is valid. Methods The PearlDiver database was queried from 2010 to 2020. The incidence of peripheral neuropathy in cervical radiculopathy was assessed. Propensity score matching was used to determine if patients with cervical radiculopathy were more likely to have peripheral nerve compression compared to controls, and vice versa, to test the DCS hypothesis. Results The database contains records of 90,772 632 patients. The incidence of carpal tunnel syndrome (CTS) or peripheral ulnar nerve compression (PUnC) in cervical radiculopathy was 9.98% and 3.15%, respectively. The incidence of both carpal tunnel syndrome and PUnC in cervical radiculopathy was 1.84%. Patients with cervical radiculopathy were more likely than matched controls to have both CTS ( P < .001) and PUnC ( P < .001). Patients with CTS ( P < .001) and with PUnC ( P < .001) were more likely to have cervical radiculopathy than the control cohort. Conclusions The incidence of DCS is reported. Patients with cervical radiculopathy are more likely than matched controls to have peripheral nerve compression, and vice versa, in support of the DCS hypothesis.

Painful vertebral osteoporotic compression fractures (OCFs) are often treated with cement augmentation, although controversies exist as to whether or not this increases the secondary fracture risk. Prevention of secondary fracture includes treatment of underlying osteoporosis. The purposes of this study were to determine (1) whether cement augmentation increases the rate of secondary fracture compared with nonoperative management, (2) whether anti-osteoporotic medications reduce the rate of secondary fracture, and (3) the rate of osteoporosis treatment with medications following vertebral OCF.The PearlDiver database was queried for all patients with a diagnosis of OCF from 2015 to 2019. Patients were excluded if they were50 years old, had a diagnosis of spinal neoplasm or infection, or underwent lumbar fusion in the perioperative period. Secondary fracture risk was assessed using univariate and multivariate logistic regression analysis, with kyphoplasty, vertebroplasty, anti-osteoporotic medications, age, gender, and Elixhauser Comorbidity Index as variables.A total of 36,145 patients were diagnosed with an OCF during the study period. Of those, 25,904 (71.7%) underwent nonoperative management and 10,241 (28.3%) underwent cement augmentation, including 1,556 who underwent vertebroplasty and 8,833 who underwent kyphoplasty. Patients who underwent nonoperative management had a secondary fracture rate of 21.8% following the initial OCF, compared with 14.5% in the vertebroplasty cohort and 18.5% in the kyphoplasty cohort, which was not a significant difference on multivariate analysis. In the entire cohort, 2,833 (7.8%) received anti-osteoporotic medications and 33,312 (92.2%) did not. The rate of secondary fracture was 10.1% in patients who received medications and 21.9% in those who did not, which was a significant difference on multivariate analysis (odds ratio = 1.23, p0.001).Cement augmentation did not alter the rate of secondary fracture, whereas anti-osteoporotic medications significantly decreased the risk of subsequent OCF by 19%. Only 7.8% of patients received a prescription for an anti-osteoporotic medication following the initial OCF.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objective: To review the evidence for the use of electromyography (EMG), motor-evoked potentials (MEPs), and somatosensory-evoked potentials (SSEPs) intraoperative neuromonitoring (IONM) strategies during lateral lumbar interbody fusion (LLIF), as well as discuss the limitations associated with each technique.Methods: A comprehensive review of the literature and compilation of findings relating to clinical studies investigating the efficacy of EMG, MEP, SSEP, or combined IONM strategies during LLIF.Results: The evidence for the use of EMG is mixed with some studies demonstrating the efficacy of EMG in preventing postoperative neurologic injuries and other studies demonstrating a high rate of postoperative neurologic deficits with EMG monitoring. Multimodal IONM strategies utilizing MEPs or saphenous SSEPs to monitor the lumbar plexus may be promising strategies based on results from a limited number of studies.Conclusion: The use of traditional EMG during LLIF remains without consensus. There is a growing body of evidence utilizing multimodal IONM with MEPs or saphenous SSEPs demonstrating a possible decrease in postoperative neurologic injuries after LLIF. Future prospective studies, with clear definitions of neurologic injury, that evaluate different multimodal IONM strategies are needed to better assess the efficacy of IONM during LLIF.

As robotics in spine surgery has progressed over the past 2 decades, studies have shown mixed results on its clinical outcomes and economic impact. In this review, we highlight the evolution of robotic technology over the past 30 years, discussing early limitations and failures. We provide an overview of the history and evolution of currently available spinal robotic platforms and compare and contrast the available features of each. We conclude by summarizing the literature on robotic instrumentation accuracy in pedicle screw placement and clinical outcomes such as complication rates and briefly discuss the future of robotic spine surgery.

Objectives To assess agreement among experts in pelvic fracture management regarding stability and need for operative repair of lateral compression (LC) type pelvic fractures with static radiographs compared to static radiographs and exam under anesthesia (EUA). Setting Online surveyPatients/Participants: Ten patients who presented to our level-1 trauma center with a pelvic ring injury were selected. Vignettes were distributed to 11 experienced pelvic surgeons. Intervention Exam under anesthesia MAIN OUTCOME MEASUREMENTS:: Agreement regarding pelvic fracture stability, need for surgical fixation. Results Agreement on stability was achieved in 4 (40%) cases without EUA compared to 8 (80%) cases with EUA. Inter-reviewer reliability was poor without EUA and moderate with EUA (0.207 vs. 0.592). Agreement on need to perform surgery was achieved in 5 (50%) cases compared to 6 (60%) cases with EUA. Inter-reviewer reliability was poor without EUA and moderate with EUA (0.250 vs. 0.432). For reference cases with agreement, surgeons were able to predict stability or instability using standard imaging in 57 of a possible 88 reviewer choices (64.8%) compared to 82 of 88 choices (93.2%) with the addition of EUA (p Conclusions EUA increased agreement among experienced pelvic surgeons regarding the assessment of pelvic ring stability and the need for operative intervention. Further research is necessary to define specific indications for which patients may benefit from EUA. Level of evidence Diagnostic Level V. See Instructions for authors for a complete description of levels of evidence.

Study Design/Setting Retrospective cohort analysis Objectives To characterize the impact of COVID-19 on utilization of the ten most common spine procedures and percentages of outpatient procedures. Methods The PearlDiver national database was queried from January 2010 to April 2021 for short (Results Overall, all ten procedures decreased 4.3% in 2020 compared to 2019 and increased 6.3% in 2021 compared to 2019. March and April of 2020 had the largest decreases, with March 2020 decreasing 18.2% and April 2020 decreasing 51.6% compared to January 2020. Despite increasing COVID cases in January 2021, overall procedure utilization decreased only 1.8% compared to January 2020, and increased later in 2021 with April 2021 case volumes increasing by 138% compared to January 2020. Outpatient utilization of short segment posterior lumbar fusion and lumbar interbody fusion significantly increased during this time ( P < .001). Conclusion The greatest impact on spine surgery volume from the COVID-19 pandemic occurred in March and April 2020. Spine procedure utilization was otherwise similar or increased compared to January 2020. Additionally, the volume of outpatient short segment posterior fusion and lumbar interbody fusions increased during this time period.

Study Design: Retrospective review of insurance database.Purpose: To investigate national trends, complications, and costs after cervical disc replacement (CDR) using an administrative insurance database representative of the United States population.Overview of Literature: As CDR continues to be used to treat patients with cervical stenosis, it is important to gain a better understanding of its use on a national level, potential complications, and cost. This information will allow for optimal patient counseling, risk stratification, and healthcare cost assessments. Several prior studies have investigated complications associated with CDR, but they have been limited by small sample size, single institution experiences, limited follow-up, and potential conflicts of interest.Methods: Patients who underwent single or multilevel CDR between 2007 and 2015 were identified using an insurance database. We collected data on annual trends, reimbursement costs, patient demographic information, hospital information, and information on complications from the time of operation to 1 year postoperative.Results: Total of 293 patients underwent either single or multilevel CDR. The number of procedures increased nonlinearly over time at an average of 17% per year, with a greater increase seen in the outpatient setting. Less than 3.7% of patients had new onset pain within 1 year after CDR. Within 1 year, 12.3% of patients reported a mechanical and/or bone-related complication. There were no patients who indicated a new nerve injury within 6 months of follow-up. Less than 3.7% of patients presented with dysphagia or dysphonia within 6 months, infection within 3 months, or a revision or reoperation within 1 year. Average reimbursement for single-level inpatient versus outpatient CDR was US $33,696.28 and US $34,675.12, respectively (p =0.29).Conclusions: This study demonstrated that the use of CDR continued to increase. The most common complication was mechanical and/or bone-related, and cost analysis demonstrated no significant difference between inpatient and outpatient CDR.

Study Design: Review. Objective: Venothromboembolic (VTE) complications, composed of deep vein thrombosis and pulmonary embolism are commonly observed in the perioperative setting. There are approximately 500 000 postoperative VTE cases annually in the United States and orthopedic procedures contribute significantly to this incidence. Data on the use of VTE prophylaxis in elective spinal surgery is sparse. This review aims to provide an updated consensus within the literature defining the risk factors, diagnosis, and the safety profile of routine use of pharmacological prophylaxis for VTE in elective spine surgery patients. Methods: A comprehensive review of the literature and compilation of findings relating to current identified risk factors for VTE, diagnostic methods, and prophylactic intervention and safety in elective spine surgery. Results: VTE prophylaxis use is still widely contested in elective spine surgery patients. The outlined benefits of mechanical prophylaxis compared with chemical prophylaxis varies among practitioners. Conclusion: The benefits of any form of VTE prophylaxis continues to remain a controversial topic in the elective spine surgery setting. A specific set of guidelines for implementing prophylaxis is yet to be determined. As more risk factors for thromboembolic events are identified, the complexity surrounding intervention selection increases. The benefits of prophylaxis must also continue to be balanced against the increased risk of bleeding events and neurologic injury.

Objectives To assess agreement among pelvic surgeons regarding the interpretation of examination under anesthesia (EUA), the methodology by which EUA should be performed, and the definition of a positive examination. Design Survey. Patients/participants Ten patients who presented to our Level 1 trauma center with a pelvic ring injury were selected as clinical vignettes. Vignettes were distributed to 15 experienced pelvic surgeons. Intervention Examination under anesthesia. Main outcome measurements Agreement regarding pelvic fracture stability (defined as >80% similar responses), need for surgical fixation, definition of an unstable EUA, and method of performing EUA. Results There was agreement that a pelvic fracture was stable or unstable in 8 (80%) of 10 cases. There was agreement that fixation was required or not required in 6 (60.0%) of 10 cases. Seven (46.7%) surgeons endorsed performing a full 15-part EUA, whereas the other 8 (53.3%) used an abbreviated or alternative method. Eight (53.3%) surgeons provided a definition of what constitutes a positive EUA, whereas the remaining 7 did not endorse adhering to a strict definition. Conclusions Pelvic surgeons generally agree on what constitutes a positive or negative EUA but not necessarily the implications of a positive or negative examination. There is no clear consensus among surgeons regarding the method of performing EUA nor regarding the definition of a positive EUA. Level of evidence Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background Lymphocele is a rare complication following anterior lumbar interbody fusion with very few reported cases in the literature. We report 3 cases of lymphocele following anterior lumbar interbody fusion. Case Description In the first 2 cases, the patients presented with retroperitoneal lymphocele, and both were managed with sclerotherapy with ethanol. In the third case, the patient also presented with a retroperitoneal lymphocele and was managed instead with percutaneous drain placement. All 3 patients had subsequent resolution of the lymphoceles and their associated symptoms. Conclusions This case report reviews the diagnostic algorithm and management of lymphocele following anterior lumbar interbody fusion.

Introduction There are few published studies that investigate the surgical treatment of supination-adduction (SAD, AO/OTA 44A2.3) ankle fractures. The purpose of this study was to describe the complications and outcomes following operative fixation of SAD type 2 ankle fractures. Materials and methods We identified all SAD-2 ankle fractures that presented at our institution's two hospitals from 2006–2018. Demographics, operative data, and complications (deep infection, superficial infection, delayed union, failure of fixation, and unplanned reoperation) were recorded for all patients. Lastly, all included patients were contacted by telephone for the administration of an 8-question Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference questionnaire (PI). Univariate and multivariate analysis was performed to identify risk factors for complication or poor functional outcome score. Results 65 patients met inclusion criteria. The average time to surgery was 14 days and average follow-up was 20.5 (range: 0.4–60.9) weeks. There were 9 (13.8%) complications (4 deep infections, 3 superficial infections, 1 delayed union, 1 failure of fixation) and 6 unplanned reoperations. Univariate and multivariate analysis failed to identify any statistically significant risk factors for complication or reoperation. Eleven patients participated in the administration of PROMIS score questionnaires at a mean of 3.4 years postoperatively. The average PROMIS Physical Function T-score was 42.3 ± 11.3 and the average PROMIS Pain Interference T-score was 55.8 ± 7.8. Younger age was associated with a higher physical function score. The use of a direct medial approach to the medial malleolus was associated with a lower pain interference score. Conclusion The overall complication rate for SAD (OTA/AO 44A2.3) type 2 ankle fractures is similar to that of the general ankle fracture population. We were unable to identify risk factors for complication or reoperation. Mean patient reported outcomes are within one standard deviation of the general population. Level of evidence III, retrospective cohort study.

Study Design.: Retrospective cohort study. Objectives: To clinically evaluate saphenous nerve somatosensory-evoked potentials (SSEPs) as a reliable and predictable way to detect upper lumbar plexus injury intraoperatively during lateral lumbar trans-psoas interbody fusion (LLIF). Methods: Saphenous nerve SSEPs were obtained by stimulation of inferior medial thigh with needle electrodes and recording from transcranial potentials. The primary outcome was measured by testing reproducibility of SSEPs at baseline, changes during the procedure, and relevance to standard modalities. Significant SSEP changes were compared with actual postoperative nerve complications. The sensitivity and specificity of saphenous SSEPs to detect postoperative lumbar plexus nerve injury was calculated. Results: A total of 62 patients were included in the study. Reliable saphenous SSEPs were recorded on the LLIF approach side in 52/62 patients. Persistent saphenous SSEP reduction of amplitude of >50% in 6 cases was observed during expansion of the tubular retractor or during the procedure. Two of 6 patients postoperatively had femoral nerve sensory deficits, and 5 of 6 patients had mild femoral nerve motor weakness, all of which resolved at an average of 12 weeks postoperatively (range 2-24 weeks). One patient had saphenous SSEP changes but demonstrated intraoperative recovery and had no postoperative clinical deficits. Saphenous SSEPs demonstrated 52% to 100% sensitivity and 90% to 100% specificity for detecting postoperative femoral nerve complications. Conclusion: Saphenous SSEPs can be used to detect electrophysiological changes to prevent femoral nerve injury during LLIF. Intraoperative SSEP recovery after amplitude reduction or loss may be a prognostic factor for final clinical outcome.

Coronavirus-19 (COVID-19) has disrupted the normal delivery of healthcare for spine surgeons across the world. In this review, we will provide an overview of COVID-19's clinical features, and discuss the optimization and treatment of spine pathology during the ongoing global pandemic.

Aims To describe and analyze the mid-term functional outcomes of a large series of patients who underwent the Hoffer procedure for brachial plexus birth palsy (BPBP). Methods All patients who underwent the Hoffer procedure with minimum two-year follow-up were retrospectively reviewed. Active shoulder range of movement (ROM), aggregate modified Mallet classification scores, Hospital for Sick Children Active Movement Scale (AMS) scores, and/or Toronto Test Scores were used to assess functional outcomes. Subgroup analysis based on age and level of injury was performed. Risk factors for subsequent humeral derotational osteotomy and other complications were also assessed. A total of 107 patients, average age 3.9 years (1.6 to 13) and 59% female, were included in the study with mean 68 months (24 to 194) follow-up. Results All patients demonstrated statistically significant improvement in all functional outcomes and active shoulder abduction and external rotation ROM (p < 0.001). Patients < 2.5 years of age had higher postoperative AMS, abduction ROM and strength scores, and aggregate postoperative Toronto scores (p ≤ 0.035) compared to patients ≥ 2.5 years old. There were 17 patients (16%) who required a subsequent humeral derotational osteotomy; lower preoperative AMS external rotation scores and external rotation ROM were predictive risk factors (p ≤ 0.016). Conclusion Patients with BPBP who underwent the Hoffer procedure demonstrated significant improvement in postoperative ROM, strength, and functional outcome scores at mid-term follow-up. Patients younger than 2.5 years at the time of surgery generally had better functional outcomes. Limited preoperative external rotation strength and ROM were significantly associated with requirement for subsequent humeral derotational osteotomy. In our chort significant improvements in shoulder function were obtained after the Hoffer procedure for BPBP. Cite this article: Bone Joint J 2020;102-B(2):246–253.

Retrospective cohort study.The aim was to compare the minimally clinically important difference (MCID) across multiple patient-reported outcomes (PROs) in patients undergoing cervical disc replacement (CDR) for cervical spondylotic radiculopathy versus myeloradiculopathy.To date, a limited number of studies have demonstrated mostly similar results in patients with cervical spondylotic radiculopathy or myeloradiculopathy undergoing CDR. However, each of these previous studies have focused on statistically significant differences, which may not correlate with patient perceived improvements in outcomes or success.Patients who underwent 1 or 2-level CDR with radiculopathy versus myeloradiculopathy were identified, and prospectively collected data was retrospectively reviewed. Demographic variables, preoperative diagnosis, and operative variables were collected for each patient. The following PROs were prospectively collected: Neck Disability Index (NDI), visual analog scale (VAS)-Neck, VAS-Arm, Short Form-12 Health Survey (SF-12) Physical Component Score (PCS), SF-12 Mental Component Score (MCS), PROMIS Physical Function (PF). An MCID analysis of PROs for each diagnosis group was performed and the percentage of patients achieving the MCID was compared between the two diagnosis groups.Eight-five patients, of which 56% had radiculopathy and 44% had myeloradiculopathy. MCID analysis demonstrated that at 6-week, 12-week, and final postoperative follow-up there was no significant difference in the percentage of patients with radiculopathy or myeloradiculopathy achieving the MCID for each PRO assessed. In both diagnosis groups the percentage of patients achieving the MCID for each PRO continued to increase from the 6-week to final postoperative follow-up except for the SF-12 MCS in patients with myeloradiculopathy.The percentage of patients achieving the MCID was not significantly different at each postoperative period assessed in the radiculopathy and myeloradiculopathy groups treated with CDR. In addition, the percentage of patients achieving the MCID continued to increase from 6 weeks to final follow-up in both groups for almost all PROs assessed.

Study Design Narrative review. Objectives The purpose of this review is to outline the role of sex hormones, particularly estrogen, in the pathogenesis of degenerative disc disease (DDD). Methods A narrative review of studies discussing sex hormones and intervertebral disc (IVD) degeneration was conducted through a search of bibliographic databases to identify various mechanisms involved in effectuating DDD. Results Estrogen-deficient states negatively impact various aspects of IVD function. These internal hormone environments reflect routine changes that commonly arise with physiologic aging and can compromise IVD structural integrity through a host of processes. Additionally, allosteric molecules such as micro-RNAs (mi-RNAs) and G protein-coupled estrogen receptors (GPER) antagonists can bind to estrogen receptors and inhibit protective downstream effects with estrogen receptor signaling. Furthermore, cursory studies have observed chondrogenic effects with testosterone supplementation, although the specific mechanism remains unclear. Conclusions Regulation of sex hormones, namely estrogen and testosterone, significantly impacts the structural integrity and function of IVDs. Uncovering underlying interactions driving these regulatory processes can facilitate development of novel, clinical therapies to treat DDD.

Study Design: Biomechanics study. Objectives: To evaluate the biomechanical advantage of interfacet allograft spacers in an unstable single-level and 2-level anterior cervical discectomy and fusion (ACDF) pseudoarthrosis model. Methods: Nine single-level and 8 two-level ACDF constructs were tested. Range of motion in flexion-extension (FE), lateral bending (LB), and axial rotation (AR) at 1.5 N m were collected in 4 testing configurations: (1) intact spine, (2) ACDF with interbody graft and plate/screw, (3) ACDF with interbody graft and plate/loosened screws (loose condition), and (4) ACDF with interbody graft and plate/loosened screws supplemented with interfacet allograft spacers (rescue condition). Results: All fixation configurations resulted in statistically significant decreases in range of motion in all bending planes compared with the intact spine ( P < .05). One Level. Performing ACDF with interbody graft and plate on the intact spine reduced FE, LB, and AR 60.0%, 64.9%, and 72.9%, respectively. Loosening the ACDF screws decreased these reductions to 40.9%, 44.6%, and 52.1%. The addition of interfacet allograft spacers to the loose condition increased these reductions to 74.0%, 84.1%, and 82.1%. Two Level. Performing ACDF with interbody graft and plate on the intact spine reduced FE, LB, and AR 72.0%, 71.1%, and 71.2%, respectively. Loosening the ACDF screws decreased these reductions to 55.4%, 55.3%, and 51.3%. The addition of interfacet allograft spacers to the loose condition significantly increased these reductions to 82.6%, 91.2%, and 89.3% ( P < .05). Conclusions: Supplementation of a loose ACDF construct (pseudarthrosis model) with interfacet allograft spacers significantly increases stability and has potential applications in treating cervical pseudarthrosis.

The objective of the present study was to assess the ability of transduced rat bone marrow cells (RBMCs) that overexpress BMP-2 loaded on a three-dimensionally (3D) printed scaffold to heal a critical sized rat femoral defect. Tricalcium phosphate (TCP) scaffolds were 3D printed to fit a critical sized rat femoral defect. The RBMCs were transduced with a lentiviral (LV) vector expressing BMP-2 or GFP. The rats were randomized into the following treatment groups: (1) RBMC/LV-BMP-2 + TCP, (2) RBMC/LV-GFP + TCP, (3) nontransduced RBMCs + TCP, (4) TCP scaffold alone. The animals were euthanized at 12 weeks and evaluated with plain radiographs, microcomputed tomography (micro-CT), histology, histomorphometry, and biomechanically. Each LV-BMP-2 + TCP treated specimen demonstrated complete healing of the femoral defect on plain radiographs and micro-CT. No femurs healed in the control groups. Micro-CT demonstrated that LV-BMP-2 + TCP treated femoral defects formed 197% more bone volume compared to control groups (p < 0.05). Histologic analysis demonstrated bone formation across the TCP scaffold, uniting the femoral defect on both ends in the LV-BMP-2 + TCP treated specimens. Biomechanical assessment demonstrated similar stiffness (p = 0.863), but lower total energy to failure, peak torque, and peak displacement (p < 0.001) of the femurs treated with LV-BMP-2 + TCP when compared to the contralateral control femur. Regional gene therapy induced over-expression of BMP-2 via transduced RBMCs combined with an osteoconductive 3D printed TCP scaffold can heal a critically sized femoral defect in an animal model. The combination of regional gene therapy and 3D printed osteoconductive scaffolds has significant clinical potential to enhance bone regeneration.

Background The purpose of this study is to assess the epidemiology, population-specific treatment trends, and complications of distal radius fractures in the United States. Methods The PearlDiver database (Humana [2007–2014], Medicare [2005–2014]) was used to access US inpatient and outpatient data for all patients who had undergone operative and nonoperative treatment for a distal radius fracture in the United States. Epidemiologic analysis was performed followed by age-based stratification, to assess prevalence, treatment trends, and rates of complications. Results A total of 1,124,060 distal radius treatment claims were captured. The incidence of distal radius fractures follows a bimodal distribution with distinct peaks in the pediatric and elderly population. Fractures in the pediatric population occurred predominately in males, whereas fractures in the elderly population occurred more frequently in females. The most commonly used modality of treatment was nonoperative; however, the use of internal fixation increased significantly during the study period, from 8.75 to 20.02%, with a corresponding decrease in percutaneous fixation. The overall complication rate was 8.3%, with mechanical symptoms most frequently reported. Conclusions The last decade has seen a significant increase in the use of internal fixation as treatment modality for distal radius fractures. The impetus for this change is likely multifactorial and partly related to recent innovations including volar locking plates and an increasingly active elderly population. The implicated financial cost must be weighed against the productivity cost of maintaining independent living to determine the true burden to the healthcare system.

INTRODUCTION Both total ankle replacement (TAR) and tibiotalar arthrodesis (TTA) are used in the surgical management of ankle arthritis. Over the past decade, TAR instrumentation, techniques, and implants have improved, making the procedure more reliable and reproducible, thus making TAR more common. METHODS The Nationwide Inpatient Sample database from 2007 to 2013 was used to obtain data on patients elder than 50 years who underwent either TAR or TTA. Differences in temporal, demographic, and diagnosis trends between TAR and TTA were analyzed. RESULTS Between 2007 and 2013, 15,060 patients underwent TAR and 35,096 underwent TTA. Patients undergoing TTA had significantly more comorbidities (2.17 versus 1.55; P < 0.001). The share of TAR performed increased significantly from 2007 (14%) to 2013 (45%) (P < 0.001). From 2007 to 2013, we found a 12-fold increase in the odds of having a TAR for patients with posttraumatic osteoarthritis (P < 0.001), a 4.9-fold increase for those with primary osteoarthritis, and a 3.1-fold increase for patients with rheumatoid arthritis (P < 0.001). CONCLUSIONS Over the past decade, the frequency of TAR has increased, particularly in patients with posttraumatic arthritis and osteoarthritis. Surgeons still perform TAR in healthier patients compared with TTA; however, because surgeons become more experienced with the technique, patients are undergoing TAR at a markedly higher rate. LEVEL OF EVIDENCE Level III: retrospective comparative study.

Minimally invasive spine surgery (MISS) continues to evolve, and the advent of robotic spine technology may play a role in further facilitating MISS techniques, increasing safety, and improving patient outcomes. In this chapter we review early limitations of spinal robotic systems and go over currently available spinal robotic systems. We then summarize the evidence-based advantages of robotic spine surgery, with an emphasis on pedicle screw placement. Additionally, we review some common and expanded clinical applications of robotic spine technology to facilitate MISS. The chapter concludes with a discussion regarding the current limitations and future directions of this relatively novel technology as it applies to MISS.

Study Design: Retrospective review of private neuromonitoring databases. Objectives: To review neuromonitoring alerts in a large series of patients undergoing lateral lumbar interbody fusion (LLIF) and determine whether alerts occurred more frequently when more lumbar levels were accessed or more frequently at particular lumbar levels. Methods: Intraoperative neuromonitoring (IONM) databases were reviewed and patients were identified undergoing LLIF between L1 and L5. All cases in which at least one IONM modality was used (motor evoked potentials (MEP), somatosensory evoked potentials (SSEP), evoked electromyography (EMG)) were included in this study. The type of IONM used and incidence of alerts were collected from each IONM report and analyzed. The incidence of alerts for each IONM modality based on number of levels at which at LLIF was performed and the specific level an LLIF was performed were compared. Results: A total of 628 patients undergoing LLIF across 934 levels were reviewed. EMG was used in 611 (97%) cases, SSEP in 561 (89%), MEP in 144 (23%). The frequency of IONM alerts for EMG, SSEP and MEPs did not significantly increase as the number of LLIF levels accessed increased. No EMG, SSEP, or MEP alerts occurred at L1-L2. EMG alerts occurred in 2-5% of patients at L2-L3, L3-L4, and L4-L5 and did not significantly vary by level ( P = .34). SSEP and MEP alerts occurred more frequently at L4-L5 versus L2-L3 and L3-L4 ( P < .03). Conclusions: IONM may provide the greatest utility at L4-L5, particularly MEPs, and may not be necessary for more cephalad LLIF procedures such as at L1-L2.

Background Context Recent media coverage of overlapping surgery has led to several studies investigating public perception of concurrent and overlapping surgery, both of which involve a single attending surgeon working on two separate cases in two separate operating rooms. In concurrent surgery, the critical periods of the surgeries overlap, while in overlapping surgery they do not. The literature revealed a general lack of knowledge about these practices and strong disapproval of their use by the public. Purpose To determine the comfort level of spine surgery patients and their family members toward concurrent and overlapping surgery. Study Design/Setting This cross-sectional survey study was performed at an urban, adult academic spine surgery clinic. Patient Sample Patients and their companions who were waiting to be seen at their initial clinic visit or follow-up visit were approached to participate in the study. Outcome Measures The survey queried respondents’ baseline knowledge of and comfort level with concurrent and overlapping surgery, in addition to comfort level with different levels of surgical trainees on a 5-point Likert scale. Methods A five-section, 36-item questionnaire was administered by a research assistant to respondents over a 3-month period spanning June 2019 – August 2019. A research assistant described the terms overlapping surgery and concurrent surgery to participants of the survey using diagrams and a preformulated script after self-reported knowledge questions. Statistical analysis was performed using the chi-square test for categorical variables, and Kendall's tau-c rank correlation coefficient with ordinal independent variables for correlations. Results Knowledge about concurrent and overlapping surgery was low in our study population (8.22% and 6.16%, respectively). Over half of respondents reported that they felt comfortable with overlapping surgery (58.22%). Most respondents reported that they would like their surgeon to disclose the participation of surgical trainees (residents and fellows) in their surgery (98%). In addition, the 4th and 5th years of surgical training were associated with a significant increase in patient comfort with surgical trainee participation. There was no difference in response distribution between patients versus nonpatients. Conclusions Knowledge about concurrent and overlapping surgery remains poor in our study population. Lack of general knowledge about overlapping surgery can be a serious impediment to obtaining informed consent, and further study is required to determine the best methods to raising patient awareness.

Study design Randomized, double-blinded, controlled trial. Objective To investigate the effectiveness of local intraoperative corticosteroids at decreasing the severity of swallowing difficulty following multilevel anterior cervical discectomy and fusion (ACDF). Summary of background data Dysphagia is a common complication after ACDF, and while for most patients the symptoms are mild and transient, some patients can suffer from severe dysphagia resulting in significant postoperative morbidity. Previous studies investigating the local application of corticosteroids are limited. Methods This was a prospective, randomized, double-blinded, controlled trial of patients undergoing 2, 3, or 4 level ACDF for radiculopathy and/or myelopathy. Patients undergoing multilevel ACDF were randomized to receive local corticosteroid in the retropharyngeal space or placebo (no steroid). Dysphagia was assessed using validated outcomes including the Eating Assessment Tool-10 (Eat-10) and Swallowing Quality of Life (SWAL-QOL) Questionnaire both preoperatively and at 1 day (POD1), 2 days (POD2), and 1-month postoperatively. Results One-hundred nine patients had a complete dataset available for analysis. Eat-10 scores were significantly lower in the Steroid group on POD2 (8 vs. 16, P = 0.03) and 1-month postoperatively (2 vs. 5, P = 0.03). A comparison of the individual SWAL-QOL subscale scores demonstrated that patients in the Steroid group had better scores than the Control group in various subscales at all postoperative time points. Significant differences were noted (always in favor of the Steroid group) in 40% of subscales on POD1, 60% of subscales on POD2, and 50% of subscales at 1-month postoperatively. The Control group never had a better SWAL-QOL subscale score at any time point postoperatively. Conclusion Local administration of corticosteroid after multilevel ACDF can decrease postoperative severity and symptomatology of dysphagia during the immediate postoperative period to 1-month postoperatively. The long-term effects of local steroid administration on fusion and other complications will need to be established in future studies.Level of Evidence: 1.

Background: Given the importance of the neurovascular structures in the volar forearm, accurate diagnosis of zone 5 flexor injuries is critical. Purpose: We sought to test the hypothesis that tendinous injury would be more likely in the distal 50% of the forearm and muscle belly injury would be more likely in the proximal 50% of the forearm. Methods: From December 2015 to December 2016, we conducted a prospective clinical study of patients 18 years and older with zone 5 flexor lacerations. We excluded those with concomitant ipsilateral injuries in flexor zones 1 to 4, multiple lacerations in flexor zone 5, prior neurovascular injuries, crush injuries, patients who underwent operative exploration prior to transfer to our facility, and patients who were unable or unwilling to provide consent. Neurovascular and musculotendinous injuries on physical examination were recorded. All patients underwent operative exploration. Physical examination accuracy and the incidence of musculotendinous and neurovascular injury in the distal 50% of the forearm were compared with the proximal 50% of the forearm. Results: The distal 50% of the forearm (group 1, n = 14) had higher probability of tendon injury (64%), whereas lacerations of the proximal 50% of the forearm (group 2, n = 5) did not result in any tendinous injuries. Rather, all patients in group 2 had muscle belly injuries. There was no difference in the rate of neurovascular injury between groups. Physical examination alone was highly accurate in diagnosing nerve injuries (93%–100%) but less accurate in diagnosing arterial injuries (79%–80%) regardless of the location of injury. Conclusions: Due to the lack of tendinous injuries in proximal zone 5 lacerations, along with the accuracy of physical examination in determining the presence of neurovascular injuries, patients with lacerations in the proximal half of the forearm, without evidence of nerve or arterial injury, can likely be observed in lieu of immediate operative exploration.

STUDY DESIGN Retrospective database analysis. OBJECTIVE To identify nationwide temporal trends in management of geriatric odontoid fractures and to compare comorbidities, inpatient complications, hospital characteristics, and cost between patients receiving operative versus nonoperative management. SUMMARY OF BACKGROUND DATA The treatment of geriatric odontoid fractures remains controversial with some studies demonstrating decreased mortality and improved functional outcomes associated with operative management and significant morbidity associated with halo devices during nonoperative management. METHODS Patients between ages 65 to 90 years with odontoid fractures who underwent operative or nonoperative management between the years 2003 and 2017 were identified in the National Inpatient Sample (NIS) database. Year of injury, demographic variables, comorbidities, inpatient complications, mortality, length of stay, inpatient cost, and hospital characteristics were compared between operative and nonoperative treatment groups. RESULTS Thirty two thousand four hundred nineteen patients (average age 77 yr, 54% female) were included in the final analysis. Operative treatment occurred in 21,954 (67%) patients and nonoperative treatment occurred in 10,465 (32%). In 2003, operative treatment occurred in 46% of patients and nearly doubled to 86% in 2017, with an average increase of 3.7% per year (P

The most common traumatic orthopaedic injuries of the hindfoot and midfoot are calcaneus fractures and tarsometatarsal (TMT) fracture-dislocations (Lisfranc injury), respectively. These injuries can result in significant long-term morbidity primarily due to the development of posttraumatic osteoarthritis secondary to acute articular damage at the time of initial injury and chronic malalignment and abnormal force distribution across the foot resulting in progressive degeneration. This chapter will describe the normal anatomy and biomechanics of the hindfoot and midfoot, provide an outline for clinical evaluation, and describe both nonoperative and operative management strategies for treating symptomatic posttraumatic osteoarthritis of the hindfoot and midfoot.

Background Proximal junctional kyphosis (PJK) is a well-recognized complication following surgery for adult spinal deformity (ASD); however, definitions for PJK and its clinical implications can significantly vary by study. This study compares multiple definitions of PJK and describes incidence and clinical significance by definition. Methods From 2014 to 2019, patients with ASD who underwent spinal fusion were identified. Nine definitions of PJK were created based on previously established definitions using the following upper instrumented vertebra +2 (UIV+2) sagittal Cobb measurements: A= ≥10 postoperative AND preoperative, B = ≥10 postoperative, C = ≥10 preoperative, D = ≥15 postoperative AND preoperative, E = ≥15 postoperative, F = ≥15 preoperative, G = ≥20 postoperative AND preoperative, H = ≥20 postoperative, I = >20 preoperative. Incidence of PJK was calculated by definition. Area under the curve (AUC) was calculated based on a receiver operating characteristic to assess ability to predict proximal junctional failure (PJF). Univariate analysis was performed to assess association with postoperative Oswestry Disability Index (ODI) scores. Results Across 82 patients, the incidence of PJK and AUC by definition was as follows: A = 47%, 0.47; B = 72%, 0.65; C = 49%, 0.45; D = 27%, 0.46; E = 57%, 0.62; F = 27%, 0.46; G = 10%, 0.55; H = 40%, 0.71; I = 10%, 0.55. No definition was associated with postoperative ODI scores (P Conclusions The incidence of PJK significantly decreased with stricter definitions. Definitions utilizing only postoperative UIV+2 values had higher incidences but were more likely to capture patients who developed PJF. No definition was associated with postoperative ODI scores. UIV+2 ≥20 was best in distinguishing patients who developed PJF.

Study design This was a retrospective questionnaire study at a single academic medical center. Objective The objective of this study was to obtain information on rates of return to sport following lumbar fusion as well as sport-specific effects to improve evidence-based preoperative patient counseling. Summary of background data Lumbar spinal fusion is one of the fastest-growing surgical procedures, with the majority being in patients aged 60 years and older. Remaining active is an important consideration for elderly patients undergoing lumbar spinal fusion. Golf, swimming, and biking are common forms of recreational exercise for an older population in whom lumbar fusion is often performed. There is a lack of data in the current literature regarding rates of return to recreational sporting activities following elective lumbar fusion. Methods Following Institutional Review Board approval, all patients undergoing lumbar fusion at a single institution from 2012 to 2016 were screened and included in this study. A minimum of 1-year postoperative follow-up was required. A total of 117 patients were identified undergoing single-level or multilevel lumbar fusion during this time period. The average age was 63 years. Questionnaires were obtained to screen and identify patients who participated in 1 of 3 recreational sports before surgery (golf, swimming, and biking). Preoperative and postoperative collected outcome measures were then compared using the Student t test. Results Of the 117 identified lumbar fusion patients, 32 patients (27%) participated in 1 of the 3 most common recreational sporting activities of golf, swimming, or biking. Within the golf cohort (n=13), 100% of patients returned to recreational golfing postoperatively. There was a statistically significant reduction in Visual Analog Scale (VAS) pain scores postoperatively (6.3±3.7-1.8±2.4, P=0.01). Driving distance was reduced postoperatively (223.3±42.7-212.1±44.4 yards, P=0.042) and handicaps increased (12.8±8.4-17.0±11.4, P=0.02). Within the swimming cohort (n=9), 100% of patients returned to recreational swimming following lumbar fusion. There was a statistically significant reduction in VAS pain scores postoperatively (9.1±1.7-2.2±2.3, P=0.01). There was a trend towards increased amounts of swimming (times per week) postoperatively, however, this was not statistically significant (2.1±1.7-3.7±1.5, P=0.10). Within the biking cohort (n=10), 100% of patients returned to recreational biking following lumbar fusion. There was a statistically significant reduction in VAS pain scores postoperatively (6.7±4.0-1.3±1.7, P=0.03). There was a trend towards increased amounts of biking (times per week) postoperatively, however, this was not statistically significant (2.5±1.8-3.7±1.6 postoperatively, P=0.20). Conclusions In the cohort of patients from this study who partook in golfing, swimming or bicycling, 100% were able to return to their respective sport by 3-9 months postoperatively and all had a significant reduction in pain. With regards to golfers, lumbar fusion likely has an adverse effect on their golfing ability with an increase in handicap and an expected reduction in driving distance.

Study Design Retrospective National Database Study Objectives The aim of this study was to investigate the national trend of lumbar disc arthroplasty (LDA) utilization from 2005 to 2017. Methods Patients undergoing primary LDA between 2005 and 2017 were identified in the National Inpatient Sample (NIS) database. Year of the procedure, demographic, socioeconomic, hospital, and cost parameters were analyzed. The data was weighted using provided weights from the NIS database to generate national estimates of LDA procedure incidence. Lastly, we assessed the incidence of cervical disc arthroplasty (CDA) between 2005 and 2017 to serve as a historical comparison. Results An estimated 20 460 patients underwent primary LDA in the United States between 2005 and 2017. There was an initial decrease in LDA procedures between 2005 and 2006 and then a plateau between 2006 and 2009. From 2010 to 2013, there was a significant year-over-year decrease in annual LDA procedures performed, followed by a second plateau from 2014 to 2017. Overall, LDA procedures decreased 82% from 2005 to 2017. Over the same time, the annual incidence of CDA utilization increased 795% from approximately 474 procedures in 2005 to 4245 procedures in 2017 ( P < .01). Conclusions Lumbar disc arthroplasty utilization decreased 82% from 2005 to 2017, with a significant decrease in the rate of utilization noted after 2010. The utilization of LDA to treat selected degenerative lumbar conditions has not paralleled the increasing popularity of CDA, and, in fact, has demonstrated a nearly opposite utilization trend.