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INTRODUCTION: Adult spinal deformity (ASD) is a debilitating pathology that arises from a variety of etiologies. Spinal fusion surgery is the mainstay of treatment for those who do not achieve symptom relief with conservative interventions. Fusion surgery can be complicated by a secondary deformity termed proximal junctional kyphosis (PJK). RESEARCH QUESTION: This scoping review evaluates the modern body of literature analyzing risk factors for PJK development and organizes these factors according to a multifactorial framework based on mechanical, tissue or demographic components. MATERIALS AND METHODS: An extensive search of the literature was performed in PubMed and Embase back to the year 2010. Articles were assessed for quality. All risk factors that were evaluated and those that significantly predicted the development of PJK were compiled. The frequency that a risk factor was predictive compared to the number of times it was evaluated was calculated. RESULTS: 150 articles were reviewed. 57.3% of papers were of low quality. 76% of risk factors analyzed were focusing on the mechanical contribution to development of PJK versus only 5% were focusing on the tissue-based contribution. Risk factors that were most frequently predictive compared to how often they were analyzed were Hounsfield Units of vertebrae, UIV disc degeneration, paraspinal muscle cross sectional area and fatty infiltration, ligament augmentation, instrument characteristics, postoperative hip and lower extremity radiographic metrics, and postoperative teriparatide supplementation. DISCUSSION AND CONCLUSION: This review finds a multifactorial framework accounting for mechanical, patient and tissue-based risk factors will improve the understanding of PJK development.

Degenerative spinal pathology is a widespread medical issue, and spine fusion surgeries are frequently performed. In this study, we fabricated an injectable bioactive click chemistry polymer cement for use in spinal fusion and bone regrowth. Taking advantages of the bioorthogonal click reaction, this cement can be crosslinked by itself eliminating the addition of a toxic initiator or catalyst, nor any external energy sources like UV light or heat. Furthermore, nano‐hydroxyapatite (nHA) and microspheres carrying recombinant human bone morphogenetic protein‐2 (rhBMP‐2) and recombinant human vascular endothelial growth factor (rhVEGF) were used to make the cement bioactive for vascular induction and osteointegration. After implantation into a rabbit posterolateral spinal fusion (PLF) model, the cement showed excellent induction of new bone formation and bridging bone, achieving results comparable to autograft control. This is largely due to the osteogenic properties of nano‐hydroxyapatite (nHA) and the released rhBMP‐2 and rhVEGF growth factors. Since the availability of autograft sources is limited in clinical settings, this injectable bioactive click chemistry cement may be a promising alternative for spine fusion applications in addressing various spinal conditions. [ABSTRACT FROM AUTHOR]

Background: With life expectancy on the rise, there has been an increase in patients with concomitant degenerative hip and spine pathology, defined as hip-spine syndrome (HSS). Patients affected by HSS may require both total hip arthroplasty (THA) and lumbar spinal fusion (LSF), although there is a paucity of data regarding how the sequential timing of these procedures may influence clinical outcomes. This study aims to compare complications and spinopelvic parameters in patients with HSS who underwent either LSF first or THA first. Methods: A systematic search of PubMed and Scopus was conducted for randomized and nonrandomized studies investigating complications and spinopelvic parameters in patients with HSS who had undergone THA and LSF. The Methodological Index for Non-Randomized Studies (MINORS) tool was utilized to assess the risk of bias in included studies. Relevant outcomes were pooled for meta-analysis. Results: Eleven articles were included in this study. There was a significantly higher THA dislocation rate in patients who had undergone LSF first compared to those who had THA first (OR: 3.17, 95% CI 1.23–8.15, P = 0.02). No significant difference was found in terms of THA aseptic loosening (OR: 0.86; 95% CI 0.32–2.32, p = 0.77) and revision rate (OR: 1.18, 95% CI: 0.53–2.62) between these two groups. Individuals who received THA only showed a significantly lower risk of hip dislocation (OR: 0.14, 95% CI: 0.08–0.25, P < 0.00001) and THA revision (OR: 0.22, 95% CI: 0.14–0.36, P < 0.00001) compared to patients with a previous LSF. Conclusions: In HSS patients who underwent both LSF and THA, those who received LSF first displayed an increased risk of hip dislocation after subsequent THA. Additionally, the relative risks of dislocation and revision rate appeared significantly lower in patients who had undergone THA only when compared to THA patients with a history of previous LSF. Due to the impact of LSF on spinopelvic biomechanics, caution must be exercised when performing THA in individuals with instrumented spines. PROSPERO ID: CRD42023412447. Level of evidence: LL. [ABSTRACT FROM AUTHOR]

Purpose of Review: Spinal fusion, vital for treating various spinal disorders, has evolved since the introduction of the minimally invasive Lateral Lumbar Interbody Fusion (LLIF) by Pimenta in 2001. Traditionally performed in the lateral decubitus position, LLIF faces challenges such as intraoperative repositioning, neurological complications, and lack of access to lower lumbar levels. These challenges lead to long surgery times, increased rates of perioperative complications, and increased costs. The more recently popularized prone lateral approach mitigates these issues primarily by eliminating patient repositioning, thereby enhancing surgical efficiency, and reducing operative times. This review examines the progression of spinal fusion techniques, focusing on the advantages and recent findings of the prone lateral approach compared to the traditional LLIF. Recent Findings: The prone lateral approach has shown improved patient outcomes, including lower blood loss and shorter hospital stays, and has been validated by multiple studies for its safety and efficacy compared to the LLIF approach. Significant enhancements in postoperative metrics, such as the Oswestry Disability Index, Visual Analog Scale, and radiological improvements have been noted. Comparatively, the prone lateral approach offers superior segmental lordosis correction and potentially better subjective outcomes than the lateral decubitus position. Summary: Despite these advances, both techniques present similar risks of neurological complications. Overall, the prone lateral approach has emerged as a promising alternative in lumbar interbody fusion, combining efficiency, safety, and improved clinical outcomes. [ABSTRACT FROM AUTHOR]

Abstract Background With life expectancy on the rise, there has been an increase in patients with concomitant degenerative hip and spine pathology, defined as hip-spine syndrome (HSS). Patients affected by HSS may require both total hip arthroplasty (THA) and lumbar spinal fusion (LSF), although there is a paucity of data regarding how the sequential timing of these procedures may influence clinical outcomes. This study aims to compare complications and spinopelvic parameters in patients with HSS who underwent either LSF first or THA first. Methods A systematic search of PubMed and Scopus was conducted for randomized and nonrandomized studies investigating complications and spinopelvic parameters in patients with HSS who had undergone THA and LSF. The Methodological Index for Non-Randomized Studies (MINORS) tool was utilized to assess the risk of bias in included studies. Relevant outcomes were pooled for meta-analysis. Results Eleven articles were included in this study. There was a significantly higher THA dislocation rate in patients who had undergone LSF first compared to those who had THA first (OR: 3.17, 95% CI 1.23–8.15, P = 0.02). No significant difference was found in terms of THA aseptic loosening (OR: 0.86; 95% CI 0.32–2.32, p = 0.77) and revision rate (OR: 1.18, 95% CI: 0.53–2.62) between these two groups. Individuals who received THA only showed a significantly lower risk of hip dislocation (OR: 0.14, 95% CI: 0.08–0.25, P

Due to matching biomechanical properties and significant biological activity, Mg-based implants present great potential in orthopedic applications. In recent years, the biocompatibility and therapeutic effect of magnesium-based implants have been widely investigated in trauma repair. In contrast, the R&D work of Mg-based implants in spinal fusion is still limited. This review firstly introduced the general background for Mg-based implants. Secondly, the mechanical properties and degradation behaviors of Mg and its traditional and novel alloys were reviewed. Then, different surface modification techniques of Mg-based implants were described. Thirdly, this review comprehensively summarized the biological pathways of Mg degradation to promote bone formation in neuro-musculoskeletal circuit, angiogenesis with H-type vessel formation, osteogenesis with osteoblasts activation and chondrocyte ossification as an integrated system. Fourthly, this review followed the translation process of Mg-based implants via updating the preclinical studies in fracture fixation, sports trauma repair and reconstruction, and bone distraction for large bone defect. Furthermore, the pilot clinical studies were involved to demonstrate the reliable clinical safety and satisfactory bioactive effects of Mg-based implants in bone formation. Finally, this review introduced the background of spine fusion surgeryand the challenges of biological matching cage development. At last, this review prospected the translation potential of a hybrid Mg-PEEK spine fusion cage design.

Study Design. Retrospective cohort study. Objective. To evaluate how preoperative Oswestry Disability Index (ODI) thresholds might affect minimal clinically important difference (MCID) achievement following lumbar fusion. Summary of Background Data. As payers invest in alternative payment models, some are suggesting threshold cutoffs of patientreported outcomes (PROMs) in reimbursement approvals for orthopedic procedures. The feasibility of this has not been investigated in spine surgery. Materials/Methods. We included all adult patients undergoing one to three-level primary lumbar fusion at a single urban tertiary academic center from 2014 to 2020. ODI was collected preoperatively and one year postoperatively. We implemented theoretical threshold cutoffs at increments of 10. MCID was set at 14.3. The percent of patients meeting MCID were determined among patients "approved" or "denied" at each threshold. At each threshold, the positive predictive value (PPV) for MCID attainment was calculated. Results. A total 1368 patients were included and 62.4% (N=364) achieved MCID. As the ODI thresholds increased, a greater percent of patients in each group reached the MCID. At the lowest ODI threshold, 6.58% (N= 90) of patients would be denied, rising to 20.2%, 39.5%, 58.4%, 79.9%, and 91.4% at ODI thresholds of 30, 40, 50, 60, and 70, respectively. The PPV increased from 0.072 among patients with ODI>20 to 0.919 at ODI> 70. The number of patients denied a clinical improvement in the denied category per patient achieving the MCID increased at each threshold (ODI > 20: 1.96; ODI> 30: 2.40; ODI >40: 2.75; ODI>50: 3.03; ODI> 60: 3.54; ODI> 70: 3.75). Conclusion. Patients with poorer preoperative ODI are significantly more likely to achieve MCID following lumbar spine fusion at all ODI thresholds. Setting a preoperative ODI threshold for surgical eligibility will restrict access to patients who may benefit from spine fusion despite ODI> 20 demonstrating the lowest predictive value for MCID achievement. [ABSTRACT FROM AUTHOR]

The optimal configuration for spinopelvic fixation during multilevel spine fusion surgery for adult spine deformity remains unclear. Postoperative sacroiliac (SI) joint pain, S2AI screw loosening and implant breakage could be related to continued motion of the SI joint with use of only a single point of fixation across the SI joint. Prospective, international, multicenter randomized controlled trial of 222 patients with adult spine deformity scheduled for multilevel (4 or more levels) spine fusion surgery with pelvic fixation. Subjects were randomized to sacroalar (S2) iliac (S2AI) screws alone for pelvic fixation or S2AI + triangular titanium implants placed cephalad to S2AI screws. Quad rod techniques were not allowed or used. Baseline spinal deformity measures were read by an independent radiologist. Site-reported perioperative adverse events were reviewed by a clinical events committee. Quality of life questionnaires and other clinical outcomes are in process with planned 2-year follow-up. One hundred thirteen participants were assigned to S2AI and 109 to S2AI + titanium triangular implants (TTI). 35/222 (16%) of all subjects had a history of SI joint pain or were diagnosed with SI joint pain during preoperative workup. Three-month follow-up was available in all but 4 subjects. TTI placement was successful in 106 of 109 (98%) subjects assigned to TTI. In 2 cases, TTI could not be placed due to anatomical considerations. Three TTI ventral iliac breaches were observed, all of which were managed non-surgically. One TTI subject had a transverse sacral fracture and 1 TTI subject had malposition of the implant requiring removal. SI joint pain is common in patients with adult spinal deformity who are candidates for multilevel spine fusion surgery. Concurrent placement of TTI parallel to S2AI screws during multilevel spine fusion surgery is feasible and safe. Further follow-up will help to determine the clinical value of this approach to augment pelvic fixation. [ABSTRACT FROM AUTHOR]

Objective To evaluate the global practice pattern of wound dressing use after lumbar fusion for degenerative conditions. Methods A survey issued by AO Spine Knowledge Forums Deformity and Degenerative was sent out to AO Spine members. The type of postoperative dressing employed, timing of initial dressing removal, and type of subsequent dressing applied were investigated. Differences in the type of surgery and regional distribution of surgeons’ preferences were analyzed. Results Right following surgery, 60.6% utilized a dry dressing, 23.2% a plastic occlusive dressing, 5.7% glue, 6% a combination of glue and polyester mesh, 2.6% a wound vacuum, and 1.2% other dressings. The initial dressing was removed on postoperative day 1 (11.6%), 2 (39.2%), 3 (20.3%), 4 (1.7%), 5 (4.3%), 6 (0.4%), 7 or later (12.5%), or depending on drain removal (9.9%). Following initial dressing removal, 75.9% applied a dry dressing, 17.7% a plastic occlusive dressing, and 1.3% glue, while 12.1% used no dressing. The use of no additional coverage after initial dressing removal was significantly associated with a later dressing change (p < 0.001). Significant differences emerged after comparing dressing management among different AO Spine regions (p < 0.001). Conclusion Most spine surgeons utilized a dry or plastic occlusive dressing initially applied after surgery. The first dressing was more frequently changed during the first 3 postoperative days and replaced with the same type of dressing. While dressing policies tended not to vary according to the type of surgery, regional differences suggest that actual practice may be based on personal experience rather than available evidence.

Study Design: Systematic Review. Objective: To review the literature for complications and outcomes after the implantation of cellular bone matrix (CBM) during spine fusion. Methods: The PubMed database was queried from inception to January 31, 2023 for any articles that discussed the role of and identified a specific CBM in spinal fusion procedures. Adverse events, reoperations, methods, and fusion rates were collected from all studies and reported. Results: Six hundred articles were identified, of which 19 were included that reported outcomes of 7 different CBM products. Seven studies evaluated lumbar fusion, 11 evaluated cervical fusion, and 1 study reported adverse events of a single CBM product. Only 4 studies were comparative studies while others were limited to case series. Fusion rates ranged from 68% to 98.7% in the lumbar spine and 87% to 100% in the cervical spine, although criteria for radiographic fusion was variable. While 7 studies reported no adverse events, there was no strict consensus on what constituted a complication. One study reported catastrophic disseminated tuberculosis from donor contaminated CBM. The authors of 14 studies had conflicts of interest with either the manufacturer or distributor for their analyzed CBM. Conclusions: Current evidence regarding the use of cellular bone matrix as an osteobiologic during spine surgery is weak and limited to low-grade non-comparative studies subject to industry funding. While reported fusion rates are high, the risk of severe complications should not be overlooked. Further large clinical trials are required to elucidate whether the CBMs offer any benefits that outweigh the risks. [ABSTRACT FROM AUTHOR]

Purpose: Anterior (ALIF) and transforaminal (TLIF) lumbar interbody fusion have shown similar clinical outcomes at short- and medium-term follow-ups. Possible advantages of ALIF in the long run could be better disc height and lumbar lordosis and reduced risk of adjacent segment disease. We aimed to study if ALIF could be associated with superior clinical outcomes than TLIF at long-term follow-up. Methods: We analysed 535 patients treated with ALIF or TLIF of the L5-S1 spinal segment between 2007 and 2017 who completed long-term follow-up in a national spine registry database (NORspine). We defined treatment success after surgery as at least 30% improvement in Oswestry Disability Index (ODI) at long-term follow-up. Patients treated with ALIF and TLIF and who responded at long term were balanced by propensity score matching. The proportions of successfully treated patients within each group were compared by numbers and percentages with corresponding relative risk. Results: The mean (95%CI) age of the total study population was 50 (49–51) years, and 264 (49%) were females. The mean (95%CI) preoperative ODI score was 40 (39–42), and 174 (33%) had previous spine surgery. Propensity score matching left 120 patients in each treatment group. At a median (95%CI) of 92 (88–97) months after surgery, we found no difference in proportions successfully treated patients with ALIF versus TLIF (68 (58%) versus 77 (65%), RR (95%CI) = 0.88 (0.72 to1.08); p = 0.237). Conclusions: This propensity score-matched national spine register study of patients treated with ALIF versus TLIF of the lumbosacral junction found no differences in proportions of successfully treated patients at long-term follow-up. Level of Evidence I: Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the global practice pattern of wound dressing use after lumbar fusion for degenerative conditions. Methods: A survey issued by AO Spine Knowledge Forums Deformity and Degenerative was sent out to AO Spine members. The type of postoperative dressing employed, timing of initial dressing removal, and type of subsequent dressing applied were investigated. Differences in the type of surgery and regional distribution of surgeons' preferences were analyzed. Results: Right following surgery, 60.6% utilized a dry dressing, 23.2% a plastic occlusive dressing, 5.7% glue, 6% a combination of glue and polyester mesh, 2.6% a wound vacuum, and 1.2% other dressings. The initial dressing was removed on postoperative day 1 (11.6%), 2 (39.2%), 3 (20.3%), 4 (1.7%), 5 (4.3%), 6 (0.4%), 7 or later (12.5%), or depending on drain removal (9.9%). Following initial dressing removal, 75.9% applied a dry dressing, 17.7% a plastic occlusive dressing, and 1.3% glue, while 12.1% used no dressing. The use of no additional coverage after initial dressing removal was significantly associated with a later dressing change (p < 0.001). Significant differences emerged after comparing dressing management among different AO Spine regions (p < 0.001). Conclusion: Most spine surgeons utilized a dry or plastic occlusive dressing initially applied after surgery. The first dressing was more frequently changed during the first 3 postoperative days and replaced with the same type of dressing. While dressing policies tended not to vary according to the type of surgery, regional differences suggest that actual practice may be based on personal experience rather than available evidence. [ABSTRACT FROM AUTHOR]

Introduction: Patients affected by autoimmune pathologies such as rheumatoid arthritis require surgery for various reasons. However, the systemic inflammatory nature of these disease processes often necessitates therapy with disease-modifying antirheumatic drugs (DMARDs). Alteration of these agents in the perioperative period for surgery requires a careful risk-benefit analysis to limit disease flares, infection rates, and secondary revisions. We therefore queried North and South American practices for perioperative management of DMARDs in patients undergoing elective spine surgery. Methods: An institutional review board-approved pilot survey was disseminated to spine surgeons regarding how they managed DMARDs before, during, and after spine surgery. Results: A total of 47 spine surgeons responded to the survey, 37 of whom were neurosurgeons (78.7%) and 10 orthopedic surgeons (21.3%). Of the respondents, 80.9% were from North America, 72.3% were board-certified, 51.1% practiced in academic institutions, and 66.0% performed 50-150 spine surgeries per year. Most respondents consulted a rheumatologist before continuing or withholding a DMARD in the perioperative period (70.2%). As such, a majority of the spine surgeons in this survey withheld DMARDs at an average of 13.8 days before and 19.6 days after spine surgery. Of the spine surgeons who withheld DMARDs before and after spine surgery, the responses were variable with a trend toward no increased risk of postoperative complications. Conclusions: Based on the results of this pilot survey, we found a consensus among spine surgeons to withhold DMARDs before and after elective spine surgery.

Study Design: Retrospective single-institution cohort Objective: To evaluate the implementation of a commercial bundled payment model in patients undergoing lumbar spinal fusion. Summary of Background Data: BPCI-A caused significant losses for many physician practices, prompting private payers to establish their own bundled payment models. The feasibility of these private bundles has yet to be evaluated in spine fusion. Methods: Patients undergoing lumbar fusion from October to December 2018 in BPCI-A before our institution's departure were included for BPCI-A analysis. Private bundle data was collected from 2018 to 2020. Analysis of the transition was conducted among Medicare-aged beneficiaries. Private bundles were grouped by calendar year (Y1, Y2, Y3). Stepwise multivariate linear regression was performed to measure independent predictors of net deficit. Results: The net surplus was the lowest in Y1 ($2,395, P = 0.03) but did not differ between our final year in BPCI-A and subsequent years in private bundles (all, P > 0.05). AIR and SNF patient discharges decreased significantly in all private bundle years compared with BPCI. Readmissions fell from 10.7% (N = 37) in BPCI-A to 4.4% (N = 6) in Y2 and 4.5% (N= 3) Y3 of private bundles (P < 0.001). Being in Y2 or Y3 was independently associated with a net surplus in comparison to the Y1 (β: $11,728, P = 0.001; β: $11,643, P = 0.002). Postoperatively, length of stay in days (β: $-2,982, P < 0.001), any readmission (β: -$18,825, P = 0.001), and discharge to AIR (β: $-61,256, P < 0.001) or SNF (β: $-10,497, P = 0.058) were all associated with a net deficit. Conclusions: Nongovernmental bundled payment models can be successfully implemented in lumbar spinal fusion patients. Constant price adjustment is necessary so bundled payments remain financially beneficial to both parties and systems overcome early losses. Private insurers who have more competition than the government may be more willing to provide mutually beneficial situations where cost is reduced for payers and health systems. [ABSTRACT FROM AUTHOR]

Degenerative spine disease is increasing in prevalence as the global population ages, indicating a need for targeted therapies and continued innovations. While autograft and allograft have historically demonstrated robust results in spine fusion surgery, they have significant limitations and associated complications such as infection, donor site morbidity and pain, and neurovascular injury. Synthetic grafts may provide similar success while mitigating negative outcomes. A narrative literature review was performed to review available synthetic materials that aim to optimize spinal fusion. The authors specifically address the evolution of synthetics and comment on future trends. Novel synthetic materials currently in use include ceramics, synthetic polymers and peptides, bioactive glasses, and peptide amphiphiles, and the authors focus on their success in both human and animal models, physical properties, advantages, and disadvantages. Advantages include properties of osteoinduction, osteoconduction, and osteogenesis, whereas disadvantages encompass a lack of these properties or growth factor-induced complications. Typically, the use of synthetic materials results in fewer complications and lower costs. While the development and tuning of synthetic materials are ongoing, there are many beneficial alternatives to autografts and allografts with promising fusion results. [ABSTRACT FROM AUTHOR]

To evaluate the impact of frailty, as measured by the 5-factor modified Frailty Index (mFI-5) and the Risk Analysis Index (RAI), on advanced care facility discharge (FD) in patients who underwent lumbar fusion for lumbar degenerative spine disease. The American College of Surgeons National Surgical Quality Improvement Program (2012–2020) was queried for adults (≥18 years) undergoing lumbar fusion for lumbar degenerative disease. Descriptive statistics and univariate crosstabulation were used to assess baseline demographics, preoperative comorbidities, and postoperative outcomes. Receiver operating characteristic curve analysis was used to assess the discriminative threshold of the mFI-5 and RAI on FD within this population. The median patient age in this study cohort (N = 7153) was 56 years and FD occurred in 7.3% of cases. Receiver operating characteristic curve analysis demonstrated that both the mFI-5 and the RAI accurately predicted FD (C-statistics: mFI-5: 0.627; RAI: 0.746). DeLong's test found that the RAI had superior discrimination when compared to the mFI-5 (P < 0.0001). RAI is a reliable predictor of FD in lumbar degenerative disease patients who underwent lumbar interbody fusion and demonstrated superior discrimination compared to the mFI-5. Identification of patients at risk for FD may facilitate more precise risk stratification to enable better preoperative decision-making and help set more realistic expectations of care. [ABSTRACT FROM AUTHOR]

Background: There has been increased interest in exploring methods to reduce postoperative pain without opioid medications. In 2015, a multimodal analgesia protocol was used involving the perioperative use of celecoxib, gabapentin, intravenous acetaminophen, lidocaine, and liposomal bupivacaine. Overall, the goal was to reduce the utilization of scheduled opioids in favor of nonopioid pain management. Methods: The results of a consecutive series of 1- to 2-level open primary lumbar fusions were compared to a cohort of patients after the implementation the perioperative multimodal pain management protocol. Primary endpoints included patient-reported pain scores and secondary endpoints included length of stay. Results: There were 87 patients in the preprotocol cohort and 184 in the protocol cohort. Comparing protocol and preprotocol patients, there were no significant differences in patient demographics. There was significantly average lower pain in the protocol group on postoperative day (POD) 1 (4.50 vs 5.00, P < 0.02) and POD2 (4.42 vs 5.50, P < 0.03). There was a lower pain score on POD0 (4.80 vs 5.00), but it was only clinically significant. There was a correlation between pain and duration of surgery in the preprotocol patients (POD0 R = 0.23, POD1 R = 0.02, POD2 R = 0.38), but not in the protocol patients (POD0 R = -0.05, POD1 R = -0.08, POD2 R = -0.04). There was a shorter length of stay in the protocol cohort (2.0 vs 3.0, P < 0.01). Finally, there was an approximately 35% reduction in morphine milligram equivalents of opioids in the protocol vs preprotocol cohorts (36.2 vs 57.0, P < 0.05). Conclusion: Our novel multimodal pain management protocol significantly reduced postoperative pain, length of stay, and opioid consumption in this patient cohort. Opioid usage correlated to pain in the protocol patients, while the preprotocol patients had no correlation between opioid use and pain medication. Clinical Relevance: In this study, we demonstrated that preoperative and intraoperative analgesia can reduce postoperative pain medication requirements. Furthermore, we introduced a novel concept of a correlation of pain with opioid consumption as a marker of effective pain management of breakthrough pain. [ABSTRACT FROM AUTHOR]

Our goal was to assess teriparatide's (TP) effectiveness in improving radiographic and functional outcomes after spinal fusion surgery. This meta-analysis included randomized controlled trials (RCTs) and comparative cohort studies. The findings provide valuable insights and guidance for surgeons treating osteoporotic patients undergoing spinal fusion surgery. We conducted a systematic review to assess TP's efficacy in spinal fusion surgery for osteoporosis. Through thorough selection, data extraction, and quality assessment, we employed network meta-analysis to evaluate radiographic outcomes (fusion rate, screw loosening, vertebral fracture) and changes in bone mineral density measured by Hounsfield units. Functional outcomes were assessed using the Oswestry Disability Index scales. Our study aims to comprehensively understand TP's impact and effectiveness in spinal fusion surgery. A total of 868 patients were included in the analysis. All patients underwent thoracolumbar internal fixation fusion surgery and were divided into following 2 groups: the TP treatment group and the control group. The results revealed significant differences in radiological outcomes. The fusion rate showed a significant difference, as well as screw loosening, and bone mineral density measured in Hounsfield units. However, there was no significant difference in vertebral fracture. The TP group demonstrated favorable effects with statistical significance. In terms of functional outcomes, there was no significant difference in the assessment of Oswestry Disability Index scores between the 2 treatment groups. The meta-analysis demonstrated that the TP group exhibited significantly better outcomes, particularly in radiological measures, when compared to the control group. The use of TP in spinal fusion surgery shows promise in reducing postoperative complications and providing overall benefits. [ABSTRACT FROM AUTHOR]

Introduction: Patients with cerebral palsy (CP) may receive intrathecal baclofen (ITB) to reduce muscle spasticity and dystonia. It can be challenging to identify the proper dose of ITB, and anecdotally these dosing needs may change after spinal fusion surgery. This study aimed to evaluate the need for changes in ITB dosing following a spinal fusion in pediatric neuromuscular scoliosis (NMS) patients and identify predisposing factors for those changes. Methods: This was a retrospective case-control study of NMS patients with an ITB pump who later received a spinal fusion surgery. Dosing changes and the indications for the changes were postoperatively noted. Demographics, preoperative factors, and surgical factors were evaluated for correlation with dosing changes. Results: A total of 49 patients were included in this study. Most had no change in ITB dose (71.4%), and others required a change that averaged about 10%. Male patients, those with larger pumps, and those that had a longer hospital stay were more likely to require a decrease in dose. Complications were similar between groups. Three catheters were revised during surgery: two continued on the same dose and one required an increase in dose after surgery. Conclusions: Spinal fusion after ITB pump placement is feasible and safe. Most patients did not require dosing changes after spine fusion; however, careful evaluation postoperatively remains prudent.

Introduction: Adult spinal deformity (ASD) is a debilitating pathology that arises from a variety of etiologies. Spinal fusion surgery is the mainstay of treatment for those who do not achieve symptom relief with conservative interventions. Fusion surgery can be complicated by a secondary deformity termed proximal junctional kyphosis (PJK). Research question: This scoping review evaluates the modern body of literature analyzing risk factors for PJK development and organizes these factors according to a multifactorial framework based on mechanical, tissue or demographic components. Materials and methods: An extensive search of the literature was performed in PubMed and Embase back to the year 2010. Articles were assessed for quality. All risk factors that were evaluated and those that significantly predicted the development of PJK were compiled. The frequency that a risk factor was predictive compared to the number of times it was evaluated was calculated. Results: 150 articles were reviewed. 57.3% of papers were of low quality. 76% of risk factors analyzed were focusing on the mechanical contribution to development of PJK versus only 5% were focusing on the tissue-based contribution. Risk factors that were most frequently predictive compared to how often they were analyzed were Hounsfield Units of vertebrae, UIV disc degeneration, paraspinal muscle cross sectional area and fatty infiltration, ligament augmentation, instrument characteristics, postoperative hip and lower extremity radiographic metrics, and postoperative teriparatide supplementation. Discussion and conclusion: This review finds a multifactorial framework accounting for mechanical, patient and tissue-based risk factors will improve the understanding of PJK development.

Objective: Lordosis Distribution Index (LDI) is a new radiographic parameter associated with postoperative residual symptoms in patients undergoing Transforaminal Lumbar Interbody Fusion (TLIF). Recently, it has been applied on patients undergoing instrumented spine surgery, however not correlated to Patient Related Outcome Measures (PROMs). This study investigates whether the obtained the postoperative LDI after TLIF surgery correlates with the clinical outcome measured with PROMs. Methods: This study was based on prospectively obtained data in patients undergoing TLIF throughout 2017 at a Danish university hospital. Medical records and the DaneSpine Database were accessed to obtain preoperative, operative and follow-up data. Primary outcome was Oswestry Disability Index (ODI) 12 months postoperatively. Secondary outcomes included revision rate and additional PROMs. Results: 126 patients were included. 70 patients were classified with normolordosis (56 %), 42 hypolordosis (33 %) and 14 hyperlordosis (11 %). All groups experienced significant radiological changes undergoing surgery. Average reduction in ODI at 12 months postoperatively was −15.3 (±20.0). Minimally clinical important difference was achieved in 68 patients (54.0 %). No significant difference in PROMs between LDI-groups was observed in unadjusted or adjusted analyses. Revision surgery was performed in 8 patients with normolordosis (11.4 %), 7 hypolordosis (16.7 %) and 4 hyperlordosis (28.6 %). Conclusions: We found no significant correlation between postoperative LDI subgroups of normolordotic, hypo- or hyperlordotic patients and the clinical outcome of posterolateral fusion and TLIF surgery. A trend towards lower rate of revision surgery in the normolordotic group compared to the hypo- and hyperlordotic group was observed.

Background: With the increased use of cannabis in the US, there is a significant need to understand the medical complications associated with its use in relationship to a surgical population. Cannabis has mainly been studied with respect to its qualities of pain treatment, yet few studies have investigated post-surgical complications associated with its use. Therefore, the purpose of this study was to explore the effect of cannabis use on complications in spine surgery, and compare these complications rates to opioid-related complications. Methods: This was a retrospective study conducted using the PearlDiver Database. Using ICD codes 40,989 patients that underwent lumbar spine fusion between January 2010 and October 2020 were identified and divided into 3 study groups (i.e., control, patients with known opioid use disorder, and patients identified as cannabis users). Differences in the incidence of complications within 30 days of the index procedure and pseudarthrosis rates at 18 months postindex procedure were assessed among study groups using a multivariate logistic regression. Results: Of 12.4% study population used cannabis and 38.8% had a known opioid use disorder. Results indicated increased odds of experiencing a VTE, hypoxia, myocardial infarction, and arrhythmia for both opioid and cannabis users compared to controls; however, when controlling for tobacco use there were no increased odds of complications within the cannabis group. The pseudarthrosis rate was greater in cannabis users (2.4%) than in controls (1.1%). Conclusions: The pseudarthrosis rate was significantly greater in patients using cannabis and opioids compared to the control group. However, when controlling for tobacco use, results suggested a possible negative synergistic between cannabis use and concomitant tobacco use that may influence bone fusion.

This retrospective study was designed to investigate the effectiveness of using a toothbrush, which is commonly used in our daily life, for biofilm removal and infection control in the treatment of spinal infections occurring after spinal fusion surgery. Currently, a biofilm is thought to form on the surface of the metal inserted during spine fusion surgery. We aim to determine the differences in clinical outcomes between using and not using a toothbrush to remove biofilm while performing conventional drainage, curettage, and debridement. A total of 1081 patients who underwent anterior or posterior spinal fusion surgery between November 2018 and October 2022 were screened. The study included 60 patients who developed surgical site infection and underwent incision and drainage surgery either with a toothbrush (n = 20) or without a toothbrush (n = 40). Failure of infection control that requires revision surgery occurred in 2 patients (10%) in the Toothbrush group and in 14 patients (35%) in the No-Toothbrush group (p = 0.039). Thus, the rate of additional surgery was significantly lower in the Toothbrush group. Additionally, normalization of c-reactive protein levels occurred significantly faster in the Toothbrush group (p = 0.044). Therefore, using a toothbrush to treat spinal infections following spinal fusion surgery appears to have beneficial mechanical debridement effects, resulting in improved clinical results, which were also confirmed based on the electron microscopic images. [ABSTRACT FROM AUTHOR]

Although incorporating patient reported outcomes (PROMs) into practice allows healthcare systems to evaluate the value of care provided, research and policy reflecting PROMs can only be valid if they represent all patients. Few studies have evaluated socioeconomic barriers to PROM completion, and none have done so in a spine patient population. To identify patient barriers to PROM completion one year following lumbar spine fusion. Retrospective single-institution cohort study. A total of 2,984 patients undergoing lumbar fusion between 2014 and 2020 Completion of Mental Component Score (MCS-12) and Physical Component Score (PCS-12) of Short Form-12 questionnaire 1 year postoperatively. A retrospective review was conducted of all patients undergoing 1-3-level lumbar fusion at a single urban tertiary center. PROMs were queried from our prospectively managed electronic outcomes database. Patients were considered to have complete PROMs if 1-year outcomes were available. Community-level characteristics were collected from patients' zip codes using the Economic Innovation Group Distressed Communities Index. Bivariate analyses were performed to assess factors associated with PROM incompletion along with multivariate logistic regression to control for confounders. A total of 1,968 (66.0%) had incomplete 1-year PROMs. Patients with incomplete PROMs were more likely to be Black (14.5% vs 9.3%, p<.001), Hispanic (2.9% vs 1.6%, p=.027), reside in a distressed community (14.7% vs 8.5%, p<.001), and be active smokers (22.4% vs 15.5%, p<.001). On multivariate regression, Black race (OR: 1.46, p=.014, Hispanic ethnicity (OR: 2.19, p=.027), distressed community status (OR: 1.47, p=.024), workers' compensation status (OR: 2.82, p=.001), and active smoking (OR:1.31, p=.034) all were independently associated with PROM incompletion. Surgical characteristics, including primary surgeon, revision status, approach, and levels fused were not associated with PROM incompletion. Social determinants of health impact completion of PROMs. Patients completing PROMs are overwhelmingly White, non-Hispanic, and reside in wealthier communities. Efforts should be taken to provide better education regarding PROMs and ensure closer follow-up of certain subgroups of patients to avoid furthering disparities in PROM research. [ABSTRACT FROM AUTHOR]

Objective: To evaluate how preoperative anemia severity affects 90-day outcomes of spinal fusion surgery. Methods: A retrospective cohort study was conducted on adult lumbar fusion patients at a tertiary medical center. Patients were classified by World Health Organization anemia severity definitions for comparisons. Multivariate regression models were created to control for confounding variables, for all primary outcomes of transfusion requirements, non-home discharge, readmissions, complications, and length of stay. Results: A total of 2582 patients were included: 2.7% with moderate-severe anemia, 11.0% with mild anemia, and 86.3% without anemia. Moderate-severe patients had the longest hospital stay (5.03 days vs 4.14 and 3.59 days, p < 0.001) and highest risk of transfusion (52.2% vs 13.0% vs 2.69%, p < 0.001), non-home discharge (39.1% vs 27.8% vs 15.4%, p < 0.001), readmission (7.25% vs 5.99% vs 3.36%, p = 0.023), and complications (13.0% vs 9.51% vs 6.20%, p = 0.012). On multivariable logistic regression, both patients with mild and moderate-severe anemia had an increased risk of transfusion (OR: 37.3, p < 0.001; OR: 5.25, p < 0.001, respectively) and non-home discharge (OR: 2.00, p = 0.021; OR: 1.71, p = 0.001, respectively) compared to patients without anemia. Anemia severity was not independently associated with complications or 90-day readmission. On multivariable linear regression, mild anemia (β: 0.37, p = 0.001) and moderate-severe anemia (β: 1.07, p < 0.001) were independently associated with length of hospital stay. Conclusion: Patients with moderate-severe preoperative anemia are at increased risk for longer length of stay, transfusions, and non-home discharge. Improved optimization of preoperative anemia may significantly reduce healthcare utilization, and surgeons should consider these risks in preoperative planning. Level of Evidence: III [ABSTRACT FROM AUTHOR]

High serum nicotine levels increase the risk of nonunion after spinal fusion. Varenicline, a pharmaceutical adjunct for smoking cessation, is a partial agonist designed to displace and outcompete nicotine at its receptor binding site, thereby limiting downstream activation. Given its mechanism, varenicline may have therapeutic benefits in mitigating nonunion for active smokers undergoing spinal fusion. To compare fusion rate and fusion mass characteristics between cohorts receiving nicotine, varenicline, or concurrent nicotine and varenicline after lumbar fusion. Rodent noninstrumented spinal fusion model. Sixty eight-week-old male Sprague-Dawley rats weighing approximately 300 grams underwent L4-5 posterolateral fusion (PLF) surgery. Four experimental groups (control: C, nicotine: N, varenicline: V, and combined: NV [nicotine and varenicline]) were included for analysis. Treatment groups received nicotine, varenicline, or a combination of nicotine and varenicline delivered through subcutaneous osmotic pumps beginning two weeks before surgery until the time of sacrifice at age 14 weeks. Manual palpation testing, microCT imaging, bone histomorphometry, and biomechanical testing were performed on harvested spinal fusion segments. Control (p=0.016) and combined (p=0.032) groups, when compared directly to the nicotine group, demonstrated significantly greater manual palpation scores. The fusion rate in the control (93.3%) and combined (93.3%) groups were significantly greater than that of the nicotine group (33.3%) (p=0.007, both). Biomechanical testing demonstrated greater Young's modulus of the fusion segment in the control (17.1 MPa) and combined groups (34.5 MPa) compared to the nicotine group (8.07 MPa) (p<0.001, both). MicroCT analysis demonstrated greater bone volume fraction (C:0.35 vs N:0.26 vs NV:0.33) (p<0.001, all) and bone mineral density (C:335 vs N:262 vs NV:328 mg Ha/cm3) (p<0.001, all) in the control and combined groups compared to the nicotine group. Histomorphometry demonstrated a greater mineral apposition rate in the combined group compared to the nicotine group (0.34 vs 0.24 μm/day, p=0.025). In a rodent spinal fusion model, varenicline mitigates the adverse effects of high nicotine serum levels on the rate and quality of spinal fusion. These findings have the potential to significantly impact clinical practice guidelines and the use of pharmacotherapy for active nicotine users undergoing fusion surgery. [ABSTRACT FROM AUTHOR]

Abstract Background To investigate the clinical safety and efficacy of ViBone® Viable Bone Matrix (VBM), a next generation cellular bone matrix allograft that comprises all three essential bone-forming components: osteogenic, osteoinductive, and osteoconductive factors, and is optimized to enhance cell viability and bone formation. Methods This was a multi-center, prospective, post-market study evaluating the safety and efficacy of ViBone VBM in patients undergoing 1–3 level anterior cervical discectomy and fusion or lumbar interbody fusion surgery. Patients were evaluated at baseline, 6-month, and 12-month follow-up clinically and radiographically. Clinical assessment included Visual Analog Scale for pain (VAS-pain), the Neck Disability Index (NDI) for patients with cervical pathologies, and the Oswestry Disability Index (ODI) for patients with lumbar pathologies. Fusion success defined by an independent radiologist was determined radiographically by plain films. Results Clinical outcomes evaluated with VAS-pain, NDI, and ODI scales were improved significantly at 6 and 12 months compared to baseline. All patients reached clinically significant improvements at 12 months. There were no adverse events or infections attributed to ViBone VBM. At 12 months, the fusion rate per patient was 88.1% in cervical and 97.6% in lumbar patients, while per-level fusion was 98.5% for cervical and 100% for lumbar segments. Conclusions Patients undergoing cervical and lumbar spinal fusion implanted with ViBone VBM demonstrated favorable outcomes at 6 months and 12 months as measured by subjective clinical measures and radiographic fusion rates. Trial registration This study was registered as NCT03425682 on 1/29/2018.

Study designWe conducted decision analytical modeling using a Markov model to determine the ICER of i-factor compared to autograft in ACDF surgery.ObjectiveThe efficacy and safety of traditional anterior cervical discectomy and fusion (ACDF) surgery has improved with the introduction of new implants and compounds. Cost-effectiveness of these innovations remains an often-overlooked aspect of this effort. To evaluate the cost-effectiveness of i-FACTOR compared to autograft for patients undergoing ACDF surgery.MethodsThe patient cohort was extracted from a prospective, multicenter randomized control trial (RCT) from twenty-two North American centers. Patients randomly received either autograft (N = 154) or i-Factor (N = 165). We analyzed various real-world scenarios, including inpatient and outpatient surgical settings as well as private versus public insurances. Two primary outcome measures were assessed: cost and utility. In the base-case analysis, both health and societal system costs were evaluated. Health-related utility outcome was expressed in quality-adjusted life years (QALYs). Cost-effectiveness was expressed as an incremental cost-effectiveness ratio (ICER).ResultsIn all scenarios, i-FACTOR reduced costs within the first year by 1.4% to 2.1%. The savings proved to be incremental over time, increasing to 3.7% over an extrapolated 10 years. The ICER at 90 days was $13,333 per QALY and became negative ("dominated") relative to the control group within one year and onwards. In a threshold sensitivity analysis, the cost of i-FACTOR could theoretically be increased 70-fold and still remain cost-effective.ConclusionThe novel i-FACTOR is not only cost-effective compared to autograft in ACDF surgery but is the dominant economic strategy.

This study aims to understand the impact forces that surgeons apply to the human spine during a posterior spinal fusion procedure towards the development of a novel spine surgical simulator for training medical residents. The foci of this study are impact forces during graft placement and spinal interbody cage insertion. This study examined the lumbar intervertebral discs of two male cadaveric specimens. Impact forces were collected during graft and spinal cage insertion over multiple levels. An impulse hammer and a camera were used to collect impact forces and displacements, respectively. The results demonstrated a logarithmic relationship between impact forces and cumulative displacement during graft placement. This was also observed between cumulative displacement and number of impacts during spinal cage insertion. A linear relationship was observed for the impact forces and number of impacts during graft placement. Results suggest that surgeons rely on the feedback experienced from impact forces during graft insertion to gauge the amount of graft that was placed in a specific area of the disc. Impact forces during cage insertion provide information about any encountered obstacles. When developing surgical simulators, designing the force feedback system should require modelling these behaviors to effectively impart corresponding skills on a trainee. [ABSTRACT FROM AUTHOR]

CFR-PEEK is gaining popularity in spinal oncological applications due to its reduction of imaging artifacts and radiation scattering compared with titanium, which allows for better oncological follow-up and efficacy of radiotherapy. We evaluated the use of these materials for the treatment of lumbar degenerative diseases (DDs) and considered the biomechanical potential of the carbon fiber in relation to its modulus of elasticity being similar to that of bone. Twenty-eight patients with DDs were treated using CRF-PEEK instrumentation. The clinical and radiographic outcomes were collected at a 12-month FU. Spinal fusion was evaluated in the CT scans using Brantigan scores, while the clinical outcomes were evaluated using VAS, SF-12, and EQ-5D scores. Out of the patients evaluated at the 12-month FU, 89% showed complete or almost certain fusion (Brantigan score D and E) and presented a significant improvement in all clinical parameters; the patients also presented VAS scores ranging from 6.81 ± 2.01 to 0.85 ± 1.32, EQ-5D scores ranging from 53.4 ± 19.3 to 85.0 ± 13.7, SF-12 physical component scores (PCSs) ranging from 29.35 ± 7.04 to 51.36 ± 9.75, and SF-12 mental component scores (MCSs) ranging from 39.89 ± 11.70 to 53.24 ± 9.24. No mechanical complications related to the implant were detected, and the patients reported a better tolerance of the instrumentation compared with titanium. No other series of patients affected by DD that was stabilized using carbon fiber implants have been reported in the literature. The results of this pilot study indicate the efficacy and safety of these implants and support their use also for spinal degenerative diseases. [ABSTRACT FROM AUTHOR]

Study Design.: Retrospective matched cohort study. Objective.: The aim of this study was to determine whether females with idiopathic scoliosis (IS), both with and without spine fusion, experience different rates of cesarean section (CS) and epidural anesthesia (EA) than females without scoliosis. Summary of Background Data.: IS is a common spine condition with a higher prevalence in females. It is unclear whether females with scoliosis, treated nonoperatively or operatively, have different rates of cesarean delivery or EA. Materials and Methods.: Patients with IS who delivered in our integrated health care system during a 6-year period were identified (N = 1810). They were matched with a group without scoliosis who delivered during the same period (N = 1810). Rates and relative risk (RR) of CS and EA between cohorts and subgroups were calculated. Results.: The scoliosis cohort had significantly higher rates and RR of EA (P = 0.002 and P = 0.004, respectively). Scoliosis patients treated nonoperatively had an 8% greater RR of EA (P = 0.004) and had a significantly lower rate of CS (23.2% vs. 26%, P = 0.048) compared with the control group. Among only scoliosis patients, those treated with spine fusion had a 38% decreased RR of EA (P < 0.001). Distal fusion level did not seem to influence the RR of EA or CS. Conclusions.: Females with scoliosis were significantly more likely to receive EA at delivery compared with females without scoliosis. Rates and RR of cesarean delivery were not significantly lower among women with scoliosis, but females treated nonoperatively for scoliosis had a significantly lower CS rate than those without scoliosis. Females treated with spine fusion for scoliosis were far less likely to receive EA than both females without scoliosis and females with scoliosis treated nonoperatively. [ABSTRACT FROM AUTHOR]

Group patients who required open surgery for metastatic breast cancer to the spine by functional level and metastatic disease characteristics to identify factors that predispose to poor outcomes. A retrospective analysis included patients managed at 2 tertiary referral centers from 2008 to 2020. The primary outcome was a 90-day adverse event. A 2-step unsupervised cluster analysis stratified patients into cohorts using function at presentation, preoperative spine radiation, structural instability, epidural spinal cord compression (ESCC), neural deficits, and tumor location/hormone status. Comparisons were performed using χ2 test and one-way analysis of variance. Five patient "clusters" were identified. High function (HIGH) had thoracic metastases and an Eastern Cooperative Oncology Group (ECOG) score of 1.0 ± 0.8. Low function/irradiated (LOW + RADS) had preoperative radiation and the lowest Karnofsky scores (56.0 ± 10.6). Estrogen receptor or progesterone receptor (ER/PR) positive patients had >90% estrogen/progesterone positivity and moderate Karnofsky scores (74.0 ± 11.5). Lumbar/noncompressive (NON-COMP) had the fewest patients with ESCC grade 2 or 3 epidural disease (42.1%, P < 0.001). Low function/neurologic deficits (LOW + NEURO) had ESCC grade 2 or 3 disease and neurologic deficits. Adverse event rates were 25.0% in the HIGH group, 73.3% in LOW + RADS, 24.0% in ER/PR, 31.6% in NON-COMP, and 60.0% in LOW + NEURO (P = 0.003). Function at presentation, tumor hormone signature, radiation history, and epidural compression delineated postoperative trajectory. We believe our results can aid in expectation management and the identification of at-risk patients who may merit closer surveillance following surgical intervention. [ABSTRACT FROM AUTHOR]

Study designRetrospective large database study.ObjectiveTo determine the impact of cirrhosis on perioperative outcomes and resource utilization in elective spinal fusion surgery.MethodsElective spinal fusion hospitalizations in patients with and without cirrhosis were identified using ICD-9-CM codes between the years of 2009 and 2011 using the Nationwide Inpatient Sample database. Main outcome measures were in-hospital neurologic, respiratory, cardiac, gastrointestinal, renal and urinary, pulmonary embolism, wound-related complications, and mortality. Length of stay and inpatient costs were also collected. Multivariable logistic regressions were conducted to compare the in-hospital outcomes of patients with and without cirrhosis undergoing spinal fusion.ResultsA total of 1 214 694 patients underwent elective spinal fusions from 2009 to 2011. Oh these, 6739 were cirrhotic. Cirrhosis was a significant independent predictor for respiratory (odds ratio [OR] = 1.43, confidence interval [CI] 1.29-1.58; P < .001), gastrointestinal (OR = 1.72, CI 1.48-2.00; P < .001), urinary and renal (OR = 1.90, CI 1.70-2.12; P < 0.001), wound (OR = 1.36, CI 1.17-1.58; P < 0.001), and overall inpatient postoperative complications (OR = 1.43, CI 1.33-1.53; P < .001). Cirrhosis was also independently associated with significantly greater inpatient mortality (OR = 2.32, CI 1.72-3.14; P < .001). Cirrhotic patients also had significantly longer lengths of stay (5.35 vs 3.35 days; P < .001) and inpatient costs ($36 738 vs $29 068; P < .001).ConclusionsCirrhosis is associated with increased risk of perioperative complications, mortality and greater resource utilization. Cirrhotic patients undergoing spinal fusion surgeries should be counseled on these increased risks. Current strategies for perioperative management of cirrhotic patients undergoing spinal fusion surgery need improvement.

Study Design: Cross sectional study. Objectives: To analyze posts shared on Instagram referencing spinal fusion for tone, gender, activities of daily living (ADLs), rehabilitation, incision, pain, neurological injury, and content of post. Methods: Public instragram posts, which were isolated and evaluated using the hashtags "#spinefusion" and "#spinalfusion." All posts were analyzed by the authors for the variables previously listed. In total, 264 posts were included for investigation and analysis of patient perception of spine fusion through social media. Results: Of all included posts, approximately 86% of posts had a positive tone. There was statistical significance between positive tone and activities of daily living (ADLs) (P = 0.047), as well as negative tone and persistent pain (P = 0.008). Adequate return to activities of daily living is perceived by patients as a positive outcome after surgery: odds ratio (OR) (95% CI) of 2.11 (1.01-4.39). Persistent post operative pain results negatively on perceived outcomes after surgery OR = 0.38 (0.18-0.78). Conclusions: Reported outcomes after spine fusion has not been evaluated through social media avenues. This analysis of patients sharing their experience on social media after spinal fusion demonstrates that returning to activities of daily living is of the utmost importance to patients. Additionally, post-operative pain is a strong metric utilized by patients with their satisfaction after surgery. [ABSTRACT FROM AUTHOR]

Background: To investigate the clinical safety and efficacy of ViBone® Viable Bone Matrix (VBM), a next generation cellular bone matrix allograft that comprises all three essential bone-forming components: osteogenic, osteoinductive, and osteoconductive factors, and is optimized to enhance cell viability and bone formation. Methods: This was a multi-center, prospective, post-market study evaluating the safety and efficacy of ViBone VBM in patients undergoing 1–3 level anterior cervical discectomy and fusion or lumbar interbody fusion surgery. Patients were evaluated at baseline, 6-month, and 12-month follow-up clinically and radiographically. Clinical assessment included Visual Analog Scale for pain (VAS-pain), the Neck Disability Index (NDI) for patients with cervical pathologies, and the Oswestry Disability Index (ODI) for patients with lumbar pathologies. Fusion success defined by an independent radiologist was determined radiographically by plain films. Results: Clinical outcomes evaluated with VAS-pain, NDI, and ODI scales were improved significantly at 6 and 12 months compared to baseline. All patients reached clinically significant improvements at 12 months. There were no adverse events or infections attributed to ViBone VBM. At 12 months, the fusion rate per patient was 88.1% in cervical and 97.6% in lumbar patients, while per-level fusion was 98.5% for cervical and 100% for lumbar segments. Conclusions: Patients undergoing cervical and lumbar spinal fusion implanted with ViBone VBM demonstrated favorable outcomes at 6 months and 12 months as measured by subjective clinical measures and radiographic fusion rates. Trial registration This study was registered as NCT03425682 on 1/29/2018. [ABSTRACT FROM AUTHOR]

Study design: Systematic Review and Meta-analysis. Objective: Surgical alternatives to treat lumbar spinal stenosis and instability include indirect (ALIF, OLIF, and LLIF) and direct (TLIF or posterior lumbar interbody fusion) decompression and fusion interventions. Although both approaches have proven to be effective in reducing symptoms, it is unknown if there is any difference in effectiveness between them. In this systematic review and meta-analysis, we aimed to evaluate postoperative pain and disability in patients treated whit indirect vs direct decompression and fusion approaches. Methods: We conducted a systematic review of the literature consulting several databases and identified studies that enrolled patients diagnosed with degenerative lumbar spinal stenosis and instability treated with indirect or direct decompression and fusion techniques. Our primary endpoints were the visual analogue scale, Oswestry Disability Index, and the Japanese Orthopedics Association Back Pain Evaluation Questionnaire 1 year after the procedure. Secondary outcomes included complication rate, blood loss, and surgical time. Results: Nine retrospective and comparative studies were included enrolling a total of 1004 participants. Both surgical strategies had satisfactory clinical outcomes with no significant difference at 1 year. Although the complication rate was similar for both groups, the profile of the adverse events was different. In addition, patients treated with indirect decompression and fusion had significantly less blood loss and operative times. Conclusions: Indirect and direct decompression and fusion techniques are similarly effective in treating patients with lumbar spinal stenosis and instability. The ID group had significantly lower intraoperative blood loss and surgical time values. [ABSTRACT FROM AUTHOR]

Purpose: Epidural corticosteroid injections (ESI) are a mainstay of nonoperative treatment for patients with lumbar spine pathology. Recent literature evaluating infection risk following ESI after elective orthopedic surgery has produced conflicting evidence. Our primary objective was to review the literature and provide a larger meta-analysis analyzing the temporal effects of steroid injections on the risk of infection following lumbar spine surgery. Methods: We conducted a query of the PubMed, Embase, and Scopus databases from inception until April 1, 2022 for studies evaluating the risk of infection in the setting of prior spinal steroid injections in patients undergoing lumbar spine decompression or fusion. Three meta-analyses were conducted, (1) comparing ESI within 30-days of surgery to control, (2) comparing ESI within 30-days to ESI between 1 and 3 months preoperatively, and (3) comparing any history of ESI prior to surgery to control. Tests of proportions were utilized for all comparisons between groups. Study heterogeneity was assessed via forest plots, and publication bias was assessed quantiatively via funnel plots and qualitatively with the Newcastle–Ottawa Scale. Results: Nine total studies were included, five of which demonstrated an association between ESI and postoperative infection, while four found no association. Comparison of weighted means demonstrated no significant difference in infection rates between the 30-days ESI group and control group (2.67% vs. 1.69%, p = 0.144), 30-days ESI group and the > 30-days ESI group (2.34% vs. 1.66%, p = 0.1655), or total ESI group and the control group (1.99% vs. 1.70%, p = 0.544). Heterogeneity was low for all comparisons following sensitivity analyses. Conclusion: Current evidence does not implicate preoperative ESI in postoperative infection rates following lumbar fusion or decompression. Operative treatment should not be delayed due to preoperative steroid injections based on current evidence. There remains a paucity of high-quality data in the literature evaluating the impact of preoperative ESI on postoperative infection rates. Level of evidence: II. [ABSTRACT FROM AUTHOR]

Dynamic stabilization is an alternative fusion technique that aims to eliminate or at least minimize the possibility of degeneration of adjacent levels. The object of dynamic stabilization systems is to allow limited movement of the spine while maintaining stability. Based on experimental and clinical data, osteoporosis is a contraindication for the application of dynamic spinal fusion systems, due to the fact that the reduced bone density disrupts the osteointegration of the pedicle screws, resulting in an increased chance of loosening, which compromise the success of the operation. For this reason, most clinical trials analyse the effects of dynamic spinal fusion include osteoporosis in the exclusion criteria. [ABSTRACT FROM AUTHOR]

Study Design: Prospective randomized placebo controlled animal trial.Objective: Determine the effect of daily subcutaneous abaloparatide injection on the intervertebral fusion rate in rabbits undergoing posterolateral fusion.Study Of Background Data: Despite the wide utilization of spine fusion, pseudarthrosis remains prevalent, and results in increased morbidity. Abaloparatide is a novel analog of parathyroid hormone-related peptide (1-34) and has shown efficacy in a rat posterolateral spine fusion model to increase fusion rates. The effect of abaloparatide on the fusion rate in a larger animal model remains unknown.Materials and Methods: A total of 24 skeletally mature New Zealand White male rabbits underwent bilateral posterolateral spine fusion. Following surgery, the rabbits were randomized to receive either saline as control or abaloparatide subcutaneous injection daily. Specimens underwent manual assessment of fusion, radiographic analysis with both x-ray and high-resolution peripheral quantitative computed tomography, and biomechanical assessment.Results: Rabbits that received abaloparatide had a 100% (10/10) fusion rate compared with 45% (5/11) for controls ( P <0.02) as assessed by manual palpation. Radiographic analysis determined an overall mean fusion score of 4.17±1.03 in the abaloparatide group versus 3.39±1.21 for controls ( P <0.001). The abaloparatide group also had a greater volume of bone formed with a bone volume of 1209±543 mm 3 compared with 551±152 mm 3 ( P <0.001) for controls. The abaloparatide group had significantly greater trabecular bone volume fraction and trabecular thickness and lower specific bone surface and connectivity density in the adjacent levels when compared with controls. Abaloparatide treatment did not impact trabecular number or separation. There were no differences in biomechanical testing in flexion, extension, or lateral bending ( P >0.05) between groups.Conclusions: Abaloparatide significantly increased the fusion rate in a rabbit posterolateral fusion model as assessed by manual palpation. In addition, there were marked increases in the radiographic evaluation of fusion. [ABSTRACT FROM AUTHOR]

To determine the degree of lumbar lordosis (LL) correction possible via transforaminal lumbar interbody fusion (TLIF) in adult spinal deformity patients. A retrospective chart review identified patients ≥18 years of age with severe positive sagittal balance defined by the SRS-Schwab classification: pelvic incidence to LL mismatch >20°, sagittal vertical axis >9.5cm, and/or pelvic tilt >30°. All patients had surgery between 2013 to 2018 with a TLIF at L4-L5 and/or L5-S1 by the senior author (J.L.F.) with ≥2-years follow-up. Sixty-one patients (18 men, 43 women) with 85 TLIFs were included with an average age of 66 years and average follow-up of 50 months. Average lumbar lordosis (L1-S1) improved from 27° preoperative to 48° postoperative and 45° at 2-year follow-up (P < 0.001). Average segmental lordosis at L4-L5 TLIF sites improved from 3° preoperative to 13° postoperative and persisted at 2-year follow-up (P < 0.001). Segmental lordosis at L5-S1 TLIF sites improved from 7° preoperative to 21° postoperative and 20° at 2-year follow-up (P < 0.001). Seventeen of the TLIFs (20%) had >20° of segmental lordosis improvement at long-term follow-up. The rate of revision surgery for pseudoarthrosis at the TLIF level was 5%. Significant lordosis correction can be achieved through an open TLIF in patients with severe positive sagittal balance when utilizing meticulous deformity correction techniques, avoiding the added morbidity of an anterior approach or a 3-column osteotomy. [ABSTRACT FROM AUTHOR]

Due to their immunosuppressive potential and ability to differentiate into multiple musculoskeletal cell lineages, mesenchymal stromal cells (MSCs) became popular in clinical trials for the treatment of musculoskeletal disorders. The aim of this study was to isolate and characterize native populations of MSCs from human cortical and cancellous bone from the posterior elements of the lumbar spine and determine what source of MSCs yields better quality and quantity of cells to be potentially used for spinal fusion repair. We were able to show that MSCs from trabecular and cortical spine had the typical MSC morphology and expression markers; the ability to differentiate in adipocyte, chondrocyte, or osteoblast but they did not have a consistent pattern in the expression of the specific differentiation lineage genes. Moreover, MSCs from both sites demonstrated an immune suppression profile suggesting that these cells may have a more promising success in applications related to immunomodulation more than exploring their ability to drive osteogenesis to prevent nonunion in spine fusion procedures. [ABSTRACT FROM AUTHOR]

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

Background: Degenerative spondylolisthesis (DS) is one of the most common pathologies spine surgeons treat. While a number of potential factors have been identified, there is no current consensus on which variables most impact the decision to fuse vs. decompress alone in this population.Purpose: The purpose of this study was to describe current DS treatment practices and identify both the radiographic and clinical factors leading to the decision to fuse segments for one level DS.Study Design/setting: Descriptive cross-sectional survey.Patient Sample: Surveys were administered to members of Lumbar Spine Research Society and Society of Minimally Invasive Spine Surgery.Outcome Measures: Surgeon demographics and treatment practices were reported. Radiographic and clinical parameters were ranked by each surgeon with regards to their importance.Methods: The primary analysis was limited to completed surveys. Baseline characteristics were summarized. Clinical and radiographic parameters were ranked and compared. Ranking of each clinical and radiographic parameters was reported using best and worst rank, mean rank position, and percentiles. The most important, top 3 most important, and top 5 most important parameters were ordered given each parameter's ranking frequency.Results: 381 surveys were returned completed. With regards to fusion vs. decompression, 19.9% fuse all cases, 39.1% fuse > 75%, 17.8% fuse 50%-75%, and 23.2% fuse <25%. The most common decompressive technique was a partial laminotomy (51.4%), followed by full laminectomy (28.9%). 82.2% of respondents instrument all fusion cases. Instability (93.2%), spondylolisthesis grade (59.8%), and laterolisthesis (37.3%) were the most common radiographic factors impacting the decision to fuse. With regards to the clinical factors leading to fusion, mechanical low back pain (83.2%), activity level (58.3%), and neurogenic claudication (42.8%) were the top 3 clinical parameters.Conclusions: There is little consensus on the treatment of DS, with society members showing substantial variation in treatment patterns with the majority utilizing fusion for treatment. The most common radiographic parameters impacting treatment are instability, spondylolisthesis grade, and laterolisthesis while mechanical low back pain, activity level, and neurogenic claudication are the most common clinical parameters. [ABSTRACT FROM AUTHOR]

Bone grafting procedures are commonly used for the repair, regeneration, and fusion of bones in a wide range of orthopaedic surgeries, including large bone defects and spine fusion procedures. Autografts are the clinical gold standard, though recombinant human bone morphogenetic proteins (rhBMPs) are often used, particularly in difficult clinical situations. However, treatment with rhBMPs can have off-target effects and increase surgical costs, adding to patients' already high economic and mental burden. Recent studies have identified that FDA-approved immunosuppressant drug, FK506 (Tacrolimus), can also activate the BMP pathway by binding to its inhibitors. This study tested the hypothesis that FK506, as a standalone treatment, could induce osteogenic differentiation of human mesenchymal stromal cells (hMSCs), as well as functional bone formation in a rat segmental bone defect model and rabbit spinal fusion model. FK506 enhanced osteogenic differentiation and mineralization of hMSCs in vitro. Standalone treatment with FK506 delivered on a collagen sponge produced consistent bone bridging of a critically sized rat femoral defect with functional mechanical properties comparable to naïve bone. In a rabbit single level posterolateral spine fusion model, treatment with FK506 delivered on a collagen sponge successfully fused the L5-L6 vertebrae at rates comparable to rhBMP-2 treatment. These data demonstrate the ability of FK506 to induce bone formation in human cells and two challenging in vivo models, and indicate FK506 can be utilized to treat a variety of spine disorders. [Display omitted] • FK506 induced osteogenic differentiation and mineralization of hMSCs in vitro. • Standalone FK506 treatment bridged critically-sized rat femoral defects. • FK506-bridged defects had functional mechanical properties comparable to naïve bone. • FK506 fused vertebrae in a rabbit spine fusion model at rates comparable to rhBMP-2. [ABSTRACT FROM AUTHOR]

This retrospective study was designed to investigate the effectiveness of using a toothbrush, which is commonly used in our daily life, for biofilm removal and infection control in the treatment of spinal infections occurring after spinal fusion surgery. Currently, a biofilm is thought to form on the surface of the metal inserted during spine fusion surgery. We aim to determine the differences in clinical outcomes between using and not using a toothbrush to remove biofilm while performing conventional drainage, curettage, and debridement. A total of 1081 patients who underwent anterior or posterior spinal fusion surgery between November 2018 and October 2022 were screened. The study included 60 patients who developed surgical site infection and underwent incision and drainage surgery either with a toothbrush (n = 20) or without a toothbrush (n = 40). Failure of infection control that requires revision surgery occurred in 2 patients (10%) in the Toothbrush group and in 14 patients (35%) in the No-Toothbrush group (p = 0.039). Thus, the rate of additional surgery was significantly lower in the Toothbrush group. Additionally, normalization of c-reactive protein levels occurred significantly faster in the Toothbrush group (p = 0.044). Therefore, using a toothbrush to treat spinal infections following spinal fusion surgery appears to have beneficial mechanical debridement effects, resulting in improved clinical results, which were also confirmed based on the electron microscopic images.