Publications by authors named "Alexander R Vaccaro"

764 Publications

Letter to the Editor regarding "Return to Play Guidelines After Cervical Spine Injuries in American Football Athletes: A Literature-Based Review".

Spine (Phila Pa 1976) 2021 Sep 28. Epub 2021 Sep 28.

Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania Marina Del Rey Spine Center and Hospital, Marina Del Rey, California Marina Del Rey Spine Center and Hospital, Marina Del Rey, California Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1097/BRS.0000000000004230DOI Listing
September 2021

No Difference in Neck Pain or Health-Related Quality Measures Between Patients With or Without Degenerative Cervical Spondylolisthesis.

Global Spine J 2021 Sep 27:21925682211046906. Epub 2021 Sep 27.

Rothman Institute Orthopaedics, 387400Thomas Jefferson University Hospital, Philadelphia, PA, USA.

Study Design: This study is a retrospective case control.

Objectives: This study aims to determine whether cervical degenerative spondylolisthesis (DS) is associated with increased baseline neck/arm pain and inferior health quality states compared to a similar population without DS.

Methods: Patient demographics, pre-operative radiographs, and baseline PROMs were reviewed for 315 patients undergoing anterior cervical decompression and fusion (ACDF) with at least 1 year of follow-up. Patients were categorized based on the presence (S) or absence of a spondylolisthesis (NS). Statistically significant variables were further explored using multiple linear regression analysis.

Results: 49/242 (20%) patients were diagnosed with DS, most commonly at the C4-5 level (27/49). The S group was significantly older than the NS group (58.0 ± 10.7 vs 51.9 ± 9.81, = .001), but otherwise, no demographic differences were identified. Although a higher degree of C2 slope was found among the S cohort (22.5 ± 8.63 vs 19.8 ± 7.78, = .044), no differences were identified in terms of preoperative visual analogue scale (VAS) neck pain or NDI. In the univariate analysis, the NS group had significantly increased VAS arm pain relative to the S group (4.93 ± 3.16 vs 3.86 ± 3.30, = .045), which was no longer significant in the multivariate analysis.

Conclusions: Although previous reports have suggested an association between cervical DS and neck pain, we could not associate the presence of DS with increased baseline neck or arm pain. Instead, DS appears to be a relatively frequent (20% in this series) age-related condition reflecting radiographic, rather than necessarily clinical, disease.
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http://dx.doi.org/10.1177/21925682211046906DOI Listing
September 2021

Lumbar Spine Surgery and What We Lost in the Era of the Coronavirus Pandemic: A Survey of the Lumbar Spine Research Society.

Clin Spine Surg 2021 Sep 21. Epub 2021 Sep 21.

Department of Neurosurgery Stephens Family Clinical Research Institute, Carle Foundation Hospital, Urbana, IL Hackensack Meridian School of Medicine, Nutley Mountainside Medical Center, Montclair NJ Rothman Orthopaedic Institute, Philadelphia, PA Department of Electrical and Computer Engineering, The Grainger College of Engineering, Urbana, IL Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA.

Study Design: This was a survey of the surgeon members of the Lumbar Spine Research Society (LSRS).

Objective: The purpose of this study was to assess trends in surgical practice and patient management involving elective and emergency surgery in the early months of the coronavirus pandemic.

Summary Of Background Data: The novel coronavirus has radically disrupted medical care in the first half of 2020. Little data exists regarding the exact nature of its effect on spine care.

Methods: A 53-question survey was sent to the surgeon members of the LSRS. Respondents were contacted via email 3 times over a 2-week period in late April. Questions concentrated on surgical and clinical practice patterns before and after the pandemic. Other data included elective surgical schedules and volumes, as well as which emergency cases were being performed. Surgeons were asked about the status of coronavirus disease 2019 (COVID-19) virus testing. Circumstances for performing surgical intervention on patients with and without testing as well as patients testing positive were explored.

Results: A total of 43 completed surveys were returned of 174 sent to active surgeons in the LSRS (25%). Elective lumbar spine procedures decreased by 90% in the first 2 months of the pandemic, but emergency procedures did not change. Patients with "stable" lumbar disease had surgeries deferred indefinitely, even beyond 8 weeks if necessary. In-person outpatient visits became increasingly rare events, as telemedicine consultations accounted for 67% of all outpatient spine appointments. In total, 91% surgeons were under some type of confinement. Only 11% of surgeons tested for the coronavirus on all surgical patients.

Conclusions: Elective lumbar surgery was significantly decreased in the first few months of the coronavirus pandemic, and much of outpatient spine surgery was practiced via telemedicine. Despite these constraints, spine surgeons performed emergency surgery when indicated, even when the COVID-19 status of patients was unknown.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1097/BSD.0000000000001235DOI Listing
September 2021

Circumferential fusion with open versus percutaneous posterior fusion for lumbar isthmic spondylolisthesis.

Clin Neurol Neurosurg 2021 Oct 3;209:106935. Epub 2021 Sep 3.

Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA 19107, United States.

Study Design: Retrospective cohort study.

Objective: To investigate the clinical and radiographic differences between patients who underwent anterior lumber interbody fusion (ALIF) with either open or percutaneous posterior fusion for lumbar isthmic spondylolisthesis.

Summary Of Background Data: Circumferential fusion for isthmic spondylolisthesis is commonly performed with superior clinical outcomes, fusion rates, and restoration of sagittal balance when compared to posterior fusion alone. The outcomes comparing traditional open versus percutaneous posterior fusion in this setting have not been fully evaluated.

Methods: A retrospective review of patients who underwent ALIF with either traditional open or percutaneous posterior fusion for isthmic spondylolisthesis between 2014 and 2019 was conducted. Patient demographics, surgical characteristics, and radiographic and clinical outcomes were compared between groups.

Results: A total of 79 patients were included in the final analysis, with 49 in the Open group and 30 in the Percutaneous group. No differences were found with regard to demographic factors between groups including sex, body mass index (BMI), diabetic status, and smoking status. The percutaneous group had less estimated blood loss (EBL, 69.2 mL) and shorter length of stay (3.06 days) compared to the open group (446 mL, p = 0.017; 3.98 days, p = 0.003). Both groups demonstrated significant improvement in all clinical outcome measures after surgery (PCS-12, MCS-12, ODI, VAS Back, and VAS Leg scores). The percutaneous group achieved greater ∆VAS Back (Open = 3.55, Perc = 5.17; p = 0.045) and also had a significantly greater improvements in recovery ratio for VAS Back (Open: 0.43, Perc: 0.73; p = 0.037) and ODI (Open: 0.40, Perc = 0.67; p = 0.031). Regression analysis demonstrated percutaneous surgery to be significant predictor of superior improvement in VAS Back scores (β = 1.957, p = 0.027).

Conclusion: ALIF with percutaneous posterior fusion affords greater improvement in back pain and disability when compared to ALIF with open posterior fusion for isthmic spondylolisthesis.

Level Of Evidence: III.
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http://dx.doi.org/10.1016/j.clineuro.2021.106935DOI Listing
October 2021

Variations in management of A3 and A4 cervical spine fractures as designated by the AO Spine Subaxial Injury Classification System.

J Neurosurg Spine 2021 Sep 10:1-14. Epub 2021 Sep 10.

11The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.

Objective: Optimal management of A3 and A4 cervical spine fractures, as defined by the AO Spine Subaxial Injury Classification System, remains controversial. The objectives of this study were to determine whether significant management variations exist with respect to 1) fracture location across the upper, middle, and lower subaxial cervical spine and 2) geographic region, experience, or specialty.

Methods: A survey was internationally distributed to 272 AO Spine members across six geographic regions (North America, South America, Europe, Africa, Asia, and the Middle East). Participants' management of A3 and A4 subaxial cervical fractures across cervical regions was assessed in four clinical scenarios. Key characteristics considered in the vignettes included degree of neurological deficit, pain severity, cervical spine stability, presence of comorbidities, and fitness for surgery. Respondents were also directly asked about their preferences for operative management and misalignment acceptance across the subaxial cervical spine.

Results: In total, 155 (57.0%) participants completed the survey. Pooled analysis demonstrated that surgeons were more likely to offer operative intervention for both A3 (p < 0.001) and A4 (p < 0.001) fractures located at the cervicothoracic junction compared with fractures at the upper or middle subaxial cervical regions. There were no significant variations in management for junctional incomplete (p = 0.116) or complete (p = 0.342) burst fractures between geographic regions. Surgeons with more than 10 years of experience were more likely to operatively manage A3 (p < 0.001) and A4 (p < 0.001) fractures than their younger counterparts. Neurosurgeons were more likely to offer surgical stabilization of A3 (p < 0.001) and A4 (p < 0.001) fractures than their orthopedic colleagues. Clinicians from both specialties agreed regarding their preference for fixation of lower junctional A3 (p = 0.866) and A4 (p = 0.368) fractures. Overall, surgical fixation was recommended more often for A4 than A3 fractures in all four scenarios (p < 0.001).

Conclusions: The subaxial cervical spine should not be considered a single unified entity. Both A3 and A4 fracture subtypes were more likely to be surgically managed at the cervicothoracic junction than the upper or middle subaxial cervical regions. The authors also determined that treatment strategies for A3 and A4 subaxial cervical spine fractures varied significantly, with the latter demonstrating a greater likelihood of operative management. These findings should be reflected in future subaxial cervical spine trauma algorithms.
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http://dx.doi.org/10.3171/2021.3.SPINE201997DOI Listing
September 2021

Predictors of Prolonged Opioid Use After Lumbar Fusion and the Effects of Opioid Use on Patient-Reported Outcome Measures.

Global Spine J 2021 Sep 6:21925682211041968. Epub 2021 Sep 6.

387400Rothman Orthopaedic Institute, Spine Service, at Thomas Jefferson University, Philadelphia, PA, USA.

Study Design: Retrospective case series.

Objective: To determine risk factors associated with prolonged opioid use after lumbar fusion and to elucidate the effect of opioid use on patient-reported outcome measures (PROMs) after surgery.

Methods: Patients who underwent 1-3 level lumbar decompression and fusion with at least one-year follow-up were identified. Opioid data were collected through the Pennsylvania Prescription Drug Monitoring Program. Preoperative "chronic use" was defined as consumption of >90 days in the one-year before surgery. Postoperative "prolonged use" was defined as a filled prescription 90-days after surgery. PROMs included the following: Short Form-12 Health Survey PCS-12 and MCS-12, ODI, and VAS-Back and Leg scores. Logistic regression was performed to determine independent predictors for prolonged opioid use.

Results: The final analysis included 260 patients. BMI >35 (OR: .44 [.20, .90], P = .03) and current smoking status (OR: 2.73 [1.14, 6.96], P = .03) significantly predicted postoperative opioid usage. Chronic opioid use before surgery was associated with greater improvements in MCS-12 (β= 5.26 [1.01, 9.56], P = .02). Patients with prolonged opioid use self-reported worse VAS-Back (3.4 vs 2.1, P = .003) and VAS-Leg (2.6 vs 1.2, P = .03) scores after surgery. Prolonged opioid use was associated with decreased improvement in VAS-Leg over time (β = .14 [.15, 1.85], P = .02).

Conclusions: Current smoking status and lower BMI were significantly predictive of prolonged opioid use. Excess opioid use before and after surgery significantly affected PROMs after lumbar fusion.
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http://dx.doi.org/10.1177/21925682211041968DOI Listing
September 2021

Postoperative Glycemic Variability as a Predictor of Adverse Outcomes Following Lumbar Fusion.

Spine (Phila Pa 1976) 2021 Aug 31. Epub 2021 Aug 31.

Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA.

Study Design: A retrospective cross-sectional study.

Objective: This study aims to evaluate the effect size of postoperative glycemic variability on surgical outcomes among patients who have undergone one- to three-level lumbar fusion.

Summary Of Background Data: While numerous patient characteristics have been associated with surgical outcomes after lumbar fusion, recent studies have described the measuring of postoperative glycemic variability as another promising marker.

Methods: A total of 850 patients were stratified into tertiles (low, moderate, high) based on degree of postoperative glycemic variability defined by coefficient of variation (CV). Surgical site infections were determined via chart review based on the CDC definition. Demographic factors, surgical characteristics, inpatient complications, readmissions, and reoperations were determined by chart review and telephone encounters.

Results: Overall, a statistically significant difference in 90-day adverse outcomes was observed when stratified by postoperative glycemic variability. In particular, patients with high CV had higher odds of readmission (OR = 2.19 [1.17, 4.09]; P = 0.01), experiencing a surgical site infection (OR = 3.22 [1.39, 7.45]; P = 0.01), and undergoing reoperations (OR = 2.65 [1.34, 5.23]; P = 0.01) compared with patients with low CV. No significant association was seen between low and moderate CV groups. Higher CV patients were more likely to experience longer hospital stays (β: 1.03; P = 0.01). Among the three groups, high CV group experienced the highest proportion of complications.

Conclusion: Our study establishes a significant relationship between postoperative glycemic variability and inpatient complications, length of stay, and 90-day adverse outcomes. While HbA1c has classically been used as the principal marker to assess blood glucose control, our results show CV to be a strong predictor of postoperative adverse outcomes. Future high-quality, prospective studies are necessary to explore the true effect of CV, as well as its practicality in clinical practice. Nevertheless, fluctuations in blood glucose levels during the inpatient stay should be limited to improve patient results.Level of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000004214DOI Listing
August 2021

Evaluating Patient Interest in Orthopedic Telehealth Services Beyond the COVID-19 Pandemic.

Cureus 2021 Jul 20;13(7):e16523. Epub 2021 Jul 20.

Division of Hand Surgery, Rothman Orthopaedic Institute, Philadelphia, USA.

Background Patient interest and demand may have an impact on dictating the scope of orthopedic telehealth utilization beyond the coronavirus disease 2019 (COVID-19) pandemic. The purpose of this study was to assess whether current interest in orthopedic telehealth services is higher than pre-pandemic levels. Specific trends in interest, subspecialty differences, and regional differences were secondarily assessed. Methodology A Google Trends search was performed to assess orthopedic telehealth search interest over the last five years using the terms "Orthopedic surgeon/doctor/injury/pain + Telehealth" as well as subspecialty-specific terms. The results were formulated into combined search interest values (CSIVs), with a maximum possible value of 400, and compared between the pre-pandemic period, pre-vaccine period during the pandemic, and post-vaccine period. Results The pre-pandemic period mean CSIV was 40.3 (SD = 6.3), compared to 134.7 (SD = 72.1) during the pre-vaccine period, and 96.3 (SD = 4.4) during the post-vaccine period (p < 0.001). There was a positive correlation between CSIV and time (increasing weeks) during the pre-pandemic period (r = .77, p < 0.001) and no significant correlation between CSIV and time during the post-vaccine period (r = -.12, p = 0.610). Using the slope of the interest line during the post-vaccine period (y = 97.06 - 0.08x) it would take an additional 13.3 years beyond the study period to reach the mean pre-pandemic CSIV level of 40.3. Hand surgery was the subspecialty with the highest mean CSIV over the study period and general search interest was highest in Northeastern and Southeastern states during the post-vaccine period. Conclusions Orthopedic telehealth interest was growing before the COVID-19 pandemic and remains significantly elevated beyond pre-pandemic levels despite the reopening of clinical offices and vaccine availability across the country. It appears that a subset of patients will continue to seek telehealth services beyond the pandemic.
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http://dx.doi.org/10.7759/cureus.16523DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8375001PMC
July 2021

The Influence of Surgeon Experience and Subspeciality on the Reliability of the AO Spine Sacral Classification System.

Spine (Phila Pa 1976) 2021 Aug 13. Epub 2021 Aug 13.

Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA Spine Service, Orthopaedic Department, Sonnenhofspital, Bern, Switzerland Center for Spine Surgery and Neurotraumatology, BG Unfallklinik Frankfurt am Main, Frankfurt, Germany Department of Orthopaedics, Trauma and Spine Surgery, Ganga Hospital, Coimbatore, Tamil Nadu, India University Medical Center, Utrecht, the Netherlands Center for Spinal Surgery, Malteser Waldkrankenhaus St. Marien, Erlangen, Germany Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany.

Study Design: Cross-sectional survey.

Objective: To determine the influence of surgeons' level of experience and subspeciality training on the reliability, reproducibility, and accuracy of sacral fracture classification using the AO spine sacral classification system.

Summary Of Background Data: A surgeons' level of experience or subspecialty may have a significant effect on the reliability and accuracy of sacral classification given various levels of comfort with imaging assessment required for accurate diagnosis and classification.

Methods: High-resolution computerized tomography (CT) images from 26 cases were assessed on two separate occasions by 172 investigators representing a diverse array of surgical subspecialities (general orthopedics, neurosurgery, orthopedic spine, orthopedic trauma) and experience (<5, 5-10, 11-20, >20 yrs). Reliability and reproducibility were calculated with Cohen kappa coefficient (k) and gold standard classification agreement was determined for each fracture morphology and subtype and stratified by experience and subspeciality.

Results: Respondents achieved an overall k = 0.87 for morphology and k = 0.77 for subtype classification, representing excellent and substantial intraobserver reproducibility, respectively. Respondents from all four practice experience groups demonstrated excellent interobserver reliability when classifying overall morphology (k = 0.842/0.850, Assessment 1/Assessment 2) and substantial interobserver reliability in overall subtype (k = 0.719/0.751) in both assessments. General orthopedists, neurosurgeons, and orthopedic spine surgeons exhibited excellent interobserver reliability in overall morphology classification and substantial interobserver reliability in overall subtype classification. Surgeons in each experience category and subspecialty correctly classified fracture morphology in over 90% of cases and fracture subtype in over 80% of cases according to the gold standard. Correct overall classification of fracture morphology (Assessment 1: P = 0.024, Assessment 2: P = 0.006) and subtype (P2 < 0.001) differed significantly by years of experience but not by subspecialty.

Conclusion: Overall, the AO spine sacral classification system appears to be universally applicable among surgeons of various subspecialties and levels of experience with acceptable reliability, reproducibility, and accuracy.Level of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000004199DOI Listing
August 2021

Validation of the AO Spine Sacral Classification System: Reliability Among Surgeons Worldwide.

J Orthop Trauma 2021 Aug 6. Epub 2021 Aug 6.

Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA Department of Orthopaedics, Catholic University of Parana, Curitiba, Brazil Center for Spine Surgery and Neurotraumatology, BG Unfallklinik Frankfurt am Main, Frankfurt, Germany Spine Service, Orthopaedic Department, Sonnenhofspital, Bern, Switzerland Department of Orthopaedics, Trauma and Spine Surgery, Ganga Hospital, Coimbatore, India Department of Orthopaedic Surgery, Saarland University Medical Center, Homburg, Germany Center for Spinal Surgery, Malteser Waldkrankenhaus St. Marien, Erlangen, Germany Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany Department of Orthopaedics, Vancouver General Hospital, Vancouver, British Columbia, Canada Neurosurgery Division, Department of Neurology, State University of Campinas, Campinas-Sao Paulo, Brazil Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA Department of Orthopaedic Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA University Medical Center, Utrecht, the Netherlands.

Objectives: To 1) demonstrate that the AO Spine Sacral Classification System can be reliably applied by general orthopaedic surgeons, as well as subspecialists, universally around the world, and 2) delineate those injury subtypes which are most difficult to classify reliably in order to refine the classification before evaluating clinical outcomes.

Design: Agreement Study.

Setting: All level trauma centers, worldwide.

Participants: One hundred seventy-two members of the AO Trauma and AO Spine community.

Intervention: The AO Sacral Classification System was applied by each surgeon to 26 cases in two independent assessments performed 3 weeks apart.

Main Outcome Measurements: Inter-observer reliability and intra-observer reproducibility.

Results: A total of 8,097 case assessments were performed. The Kappa coefficient for inter-observer agreement for all cases was 0.72/0.75 (Assessment 1/Assessment 2), representing substantial reliability. When comparing classification grading (A/B/C) regardless of subtype, the Kappa coefficient was 0.84/0.85 corresponding to excellent reliability. The Kappa coefficients for inter-observer reliability were 0.95/0.93 for type A fractures, 0.78/0.79 for type B fractures, and 0.80/0.83 for type C fractures. The overall Kappa statistic for intra-observer reliability was 0.82 (range 0.18-1.00), representing excellent reproducibility. When only evaluating morphology type (A/B/C), the average Kappa value was 0.87 (range 0.18-1.00) representing excellent reproducibility.

Conclusion: The AO Spine Sacral Classification System is universally reliable among general orthopaedic surgeons and subspecialists worldwide, with substantial inter-observer and excellent intra-observer reliability.

Level Of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000002110DOI Listing
August 2021

Current Management of Cervical Spondylotic Myelopathy.

Clin Spine Surg 2020 Dec 18. Epub 2020 Dec 18.

Texas Spine Consultants, Addison, TX Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA.

Cervical spondylotic myelopathy (CSM) develops insidiously as degenerative changes of the cervical spine impact the spinal cord. Unfortunately, CSM is a form of spinal cord injury in older patients that often experiences delayed treatment. This summary evaluates the pathophysiology, natural history, diagnosis, and current management of CSM. Frequently, patients do not appreciate or correlate their symptomatology with cervical spine disease, and those with radiographic findings may be clinically asymptomatic. Providers should remember the classic symptoms of CSM-poor hand dexterity, new unsteady gait patterns, new onset and progressive difficulty with motor skills. An magnetic resonance imaging is required in patients with suspected CSM, but computerized tomography myelography is an alternative in patients with implants as contraindications to magnetic resonance imaging. The management of those with CSM has continued to be a controversial topic. In general, patients with incidental findings of cervical cord compression that are asymptomatic can be managed conservatively. Those with daily moderate-severe disease that significantly affects activities of daily living should be treated operatively.
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http://dx.doi.org/10.1097/BSD.0000000000001113DOI Listing
December 2020

Management of Acute Subaxial Trauma and Spinal Cord Injury in Professional Collision Athletes.

Clin Spine Surg 2021 Mar 1. Epub 2021 Mar 1.

Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Phiadelphia, PA Department of Orthopaedic Srugery, Northwestern University, Chicago, IL Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY Department of Orthopaedic Surgery, The Carrell Clinic, Dallas, TX Department of Sports Medicine, Perelman School of Medicine at the University of Pennsylvania Department of Neurosurgery, Thomas Jefferson University, Phiadelphia, PA.

Sports-related acute cervical trauma and spinal cord injury (SCI) represent a rare but devastating potential complication of collision sport injuries. Currently, there is debate on appropriate management protocols and return-to-play guidelines in professional collision athletes following cervical trauma. While cervical muscle strains and sprains are among the most common injuries sustained by collision athletes, the life-changing effects of severe neurological sequelae (ie, quadriplegia and paraplegia) from fractures and SCIs require increased attention and care. Appropriate on-field management and subsequent transfer/workup at an experienced trauma/SCI center is necessary for optimal patient care, prevention of injury exacerbation, and improvement in outcomes. This review discusses the epidemiology, pathophysiology, clinical presentation, immediate/long-term management, and current return-to-play recommendations of athletes who suffer cervical trauma and SCI.
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http://dx.doi.org/10.1097/BSD.0000000000001148DOI Listing
March 2021

PEEK Versus Titanium Static Interbody Cages: A Comparison of 1-Year Clinical and Radiographic Outcomes for 1-Level TLIFs.

Clin Spine Surg 2021 Oct;34(8):E483-E493

Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA.

Study Design: This was a retrospective cohort study.

Objective: This study evaluates the patient-reported Health Related Quality of Life outcomes and radiographic parameters of patients who underwent a single level transforaminal lumbar interbody fusion with either a polyetheretherketone (PEEK) or titanium interbody cage.

Summary Of Background Data: Spinal stenosis with instability is a common diagnosis that is often treated with interbody fusion, in particular transforaminal lumbar interbody fusion. Titanium and PEEK interbody cage properties have been extensively studied to understand their effect on fusion rates and subsidence.

Materials And Methods: A retrospective cohort study was conducted from a single, high volume, academic hospital. Health Related Quality of Life outcomes were obtained from Outcomes Based Electronic Research Database and electronic medical record chart review. Subsidence was defined as a loss of 2 mm or more in the anterior or posterior disk height. Spinopelvic alignment parameters measured were sacral slope, pelvic tilt, pelvic incidence, lumbar lordosis, segmental lordosis, and pelvic incidence-lumbar lordosis mismatch. Fusion rates were assessed by the Brantigan-Steffee criteria.

Results: The study included a total of 137 patients (108 PEEK, 29 titanium). Overall, no significant changes were noted between the 2 groups at 3 month or 1-year follow-up. Perioperatively, patients did report improvement in all outcome parameters within the PEEK and titanium groups. No significant difference was noted in subsidence rate between the 2 groups. Segmental lordosis significantly increased within the PEEK (+4.8 degrees; P<0.001) and titanium (+4.6 degrees; P=0.003) cage groups, however no difference was noted between groups. No significant difference was noted in fusion between the PEEK and titanium cage cohorts (92.6% vs. 86.2%; P=0.36).

Conclusion: Overall, while PEEK and titanium cages exhibit unique biomaterial properties, our study shows that there were no significant differences with respect to patient-reported outcomes or radiographic outcomes between the 2 groups at the 1-year follow-up time point.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BSD.0000000000001201DOI Listing
October 2021

Ergonomics in Spine Surgery.

Clin Spine Surg 2021 Jul 28. Epub 2021 Jul 28.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN Walter Reed National Military Medical Center, Bethesda, MD Rothman Orthopaedic Institute, Philadelphia, PA.

As physician burnout and wellness become increasingly recognized as vital themes for the medical community to address, the topic of chronic work-related conditions in surgeons must be further evaluated. While improving ergonomics and occupational health have been long emphasized in the executive and business worlds, particularly in relation to company morale and productivity, information within the surgical community remains relatively scarce. Chronic peripheral nerve compression syndromes, hand osteoarthritis, cervicalgia and back pain, as well as other repetitive musculoskeletal ailments affect many spinal surgeons. The use of ergonomic training programs, an operating microscope or exoscope, powered instruments for pedicle screw placement, pneumatic Kerrison punches and ultrasonic osteotomes, as well as utilizing multiple surgeons or microbreaks for larger cases comprise several methods by which spinal surgeons can potentially improve workspace health. As such, it is worthwhile exploring these areas to potentially improve operating room ergonomics and overall surgeon longevity.
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http://dx.doi.org/10.1097/BSD.0000000000001238DOI Listing
July 2021

Outcomes of Patients With Parkinson Disease Undergoing Cervical Spine Surgery for Radiculopathy and Myelopathy With Minimum 2-Year Follow-up.

Clin Spine Surg 2021 Oct;34(8):E432-E438

Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York.

Study Design: This was a retrospective cohort analysis.

Objective: To identify the impact of Parkinson disease (PD) on 2-year postoperative outcomes following cervical spine surgery (CSS).

Summary Of Background Data: (PD) patients are prone to spine malalignment and surgical interventions, yet little is known regarding outcomes of CSS among PD patients.

Materials And Methods: All patients from the Statewide Planning and Research Cooperative System with cervical radiculopathy or myelopathy who underwent CSS were included; among these, those with PD were identified. PD and non-PD patients (n=64 each) were 1:1 propensity score-matched by age, sex, race, surgical approach, and Deyo-Charlson Comorbidity Index (DCCI). Demographics, hospital-related parameters, and adverse postoperative outcomes were compared between cohorts. Logistic regression identified predictive factors for outcomes.

Results: Overall, patient demographics were comparable between cohorts, except that DCCI was higher in PD patients (1.28 vs. 0.67, P=0.028). PD patients had lengthier mean hospital stays than non-PD patients (6.4 vs. 4.1 d, P=0.046). PD patients also incurred comparable total hospital expenses ($69,565 vs. $57,388, P=0.248). Individual medical complication rates were comparable between cohorts; though PD patients had higher rates of postoperative altered mental status (4.7% vs. 0%, P=0.08) and acute renal failure (10.9% vs. 3.1%, P=0.084), these differences were not significant. Yet, PD patients experienced higher rates of overall medical complications (35.9% vs. 18.8%, P=0.029). PD patients had comparable rates of individual and overall surgical complications. The PD cohort underwent higher reoperation rates (15.6% vs. 7.8%, P=0.169) compared with non-PD patients, though this difference was not significant. Of note, PD was not a significant predictor of overall 2-year complications (odds ratio=1.57, P=0.268) or reoperations (odds ratio=2.03, P=0.251).

Conclusion: Overall medical complication rates were higher in patients with PD, while individual medical complications as well as surgical complication and reoperation rates after elective CSS were similar in patients with and without PD, though PD patients required longer hospital stays. Importantly, a baseline diagnosis of PD was not significantly associated with adverse two-year medical and surgical complications. This data may improve counseling and risk-stratification for PD patients before CSS.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BSD.0000000000001233DOI Listing
October 2021

Traumatic Atlanto-Occipital Dislocation-A Comprehensive Analysis of All Case Series Found in the Spinal Trauma Literature.

Int J Spine Surg 2021 Aug 21;15(4):724-739. Epub 2021 Jul 21.

Department of Orthopaedic Surgery and Neurosurgery at Thomas Jefferson University, Philadelphia, Pennsylvania.

Background: Traumatic atlanto-occipital dislocation (TAOD) is one of the most devastating traumatic injuries, generally associated with immediate death after high-energy trauma. The aim of this study was to perform a systematic literature review of all cases series of TAOD and present the current state of this entity.

Methods: A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only case series with at least 5 cases were included in the analysis. We focused on survival rates, diagnostic methods, delays in diagnosis, outcomes, and cases successfully treated nonoperatively.

Results: A total of 17 articles were included (16 retrospective and 1 prospective study) with 341 patients. Six studies included pediatric patients only. The mean Glasgow Coma Scale at admission was ≤8 in all studies. Many different diagnostic criteria were used, but none of them had high accuracy. The overall mortality rate was 34.8%, but the studies' designs were heterogeneous (some included only survivors). A high rate of concomitant traumatic brain injury was documented in some studies. We found it interesting that some patients were treated with cervical immobilization (37/341; 10.8%), which was generally used in less unstable injuries; however, the majority of patients were managed with an occipito-cervical fusion (193/341; 56.5%).

Conclusions: TAOD is a devastating traumatic injury, with a high mortality rate. An MRI may be recommended when there are subtle findings of TAOD and a normal computed tomography scan, such as subarachnoid hemorrhage in the posterior fossa, upper cervical injuries, or consistent neurological findings. Further studies are necessary to identify patients with mild MRI findings and TAOD that may be managed nonoperatively.
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http://dx.doi.org/10.14444/8095DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8375687PMC
August 2021

Direct Cost of Illness for Spinal Cord Injury: A Systematic Review.

Global Spine J 2021 Jul 21:21925682211031190. Epub 2021 Jul 21.

Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran.

Study Design: Systematic review.

Objective: Providing a comprehensive review of spinal cord injury cost of illness studies to assist health-service planning.

Methods: We conducted a systematic review of the literature published from Jan. 1990 to Nov. 2020 via Pubmed, EMBASE, and NHS Economic Evaluation Database. Our primary outcomes were overall direct health care costs of SCI during acute care, inpatient rehabilitation, within the first year post-injury, and in the ensuing years.

Results: Through a 2-phase screening process by independent reviewers, 30 articles out of 6177 identified citations were included. Cost of care varied widely with the mean cost of acute care ranging from $290 to $612,590; inpatient rehabilitation from $19,360 to $443,040; the first year after injury from $32,240 to $1,156,400; and the ensuing years from $4,490 to $251,450. Variations in reported costs were primarily due to neurological level of injury, study location, methodological heterogeneities, cost definitions, study populations, and timeframes. A cervical level of the injury, ASIA grade A and B, concomitant injuries, and in-hospital complications were associated with the greatest incremental effect in cost burden.

Conclusion: The economic burden of SCI is generally high and cost figures are broadly higher for developed countries. As studies were only available in few countries, the generalizability of the cost estimates to a regional or global level is only limited to countries with similar economic status and health systems. Further investigations with standardized methodologies are required to fill the knowledge gaps in the healthcare economics of SCI.
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http://dx.doi.org/10.1177/21925682211031190DOI Listing
July 2021

Reasons for delayed spinal cord decompression in individuals with traumatic spinal cord injuries in Iran: A qualitative study from the perspective of neurosurgeons.

Chin J Traumatol 2021 Jul 2. Epub 2021 Jul 2.

Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran; Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran Iran; Universal Scientific Education and Research Network (USERN), Tehran, Iran; Institute of Biochemistry and Biophysics, University of Tehran, Tehran, Iran; Visiting Professor, Spine Program, University of Toronto, Toronto, Canada; Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran. Electronic address:

Purpose: The median time from the event leading to the spinal cord injury (SCI) to the time of decompressive surgery is estimated to be 6.9 days in Iran, which is much longer than the proposed ideal time (less than 24 h) in published guidelines. The current qualitative study aimed to determine the reasons for the observed decompression surgery delay in Iran from the perspective of neurosurgeons.

Methods: This qualitative study is designed to perform content analysis on the gathered data from face-to-face semi-structured interviews with 12 Iranian neurosurgeons.

Results: The findings of the current study suggest that patient-related factors constitute more than half of the codes extracted from the interviews. Overall, the type of injury, presence of polytrauma, and surgeons' wrong attitude are the main factors causing delayed spinal cord decompression in Iranian patients from the perspective of neurosurgeons. Other notable factors include delay in transferring patients to the trauma center, delay in availability of necessary equipment, and scarce medical personnel.

Conclusion: In the perspective of neurosurgeons, the type of injury, presence of polytrauma, and surgeons' wrong attitude are the leading reasons for delayed decompressive surgery of individuals with SCI in Iran.
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http://dx.doi.org/10.1016/j.cjtee.2021.07.001DOI Listing
July 2021

The impact of preoperative motor weakness on postoperative opioid use after ACDF.

J Orthop 2021 Jul-Aug;26:23-28. Epub 2021 Jun 30.

Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA.

This study aims to determine if preoperative weakness is an isolated risk factor for prolonged postoperative opioid use after anterior cervical discectomy and fusion (ACDF). Patients with preoperative weakness were significantly more likely to have prolonged and inappropriate opioid use and have a single prescription mean morphine equivalent (MME) ≥ 200. Logistic regression isolated preoperative weakness, opioid tolerance, depression, and VAS Neck pain as independent predictors of extended opioid use. High postoperative opioid dose (MME ≥ 90) correlated with opioid tolerance, younger age, male sex, greater CCI, prior cervical surgery, and preoperative VAS Neck pain on regression.
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http://dx.doi.org/10.1016/j.jor.2021.06.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8267480PMC
June 2021

Do Patients with Back Pain-Dominant Symptoms Improve After Lumbar Surgery for Radiculopathy or Claudication?

Int J Spine Surg 2021 Aug 15;15(4):780-787. Epub 2021 Jul 15.

Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania.

Background: Currently, few studies have examined whether patients with back or leg pain-predominant symptoms fare better clinically after lumbar spine surgery; therefore, the purpose of this study was to determine whether patients with back pain-dominant symptoms improved to a similar degree as patients with mixed or leg pain-dominant symptoms after lumbar surgery.

Methods: A retrospective cohort study was conducted at a single academic center, in which patients were stratified into three groups: (1) back pain-dominant group (B) (visual analog score [VAS] back - VAS leg ≥ 1.0 point), (2) neutral group (N) (VAS back - VAS leg < 1.0 point), or (3) leg pain-dominant group (L) (VAS leg - VAS back ≥ 1.0 point), using a VAS threshold difference of 1.0 point. As a secondary analysis, the VAS leg-to-back pain (LBR) ratio was used to further stratify patients: (1) nonleg pain-dominant (NLPD) group (LBR ≤ 1.0) or (2) leg pain-dominant (LPD) group (LBR > 1.0). Patient outcomes, including physical component score of the short form-12 survey (PCS-12), mental component score of the short form-12 survey (MCS-12), and Oswestry Disability Index (ODI), were identified and compared between groups using univariate and multivariate analysis.

Results: There were no significant differences in preoperative, postoperative, or delta scores for PCS-12 or ODI scores between groups. In patients undergoing decompression surgery, those with back pain-dominant or mixed symptoms (B, N, or NLPD groups) did not improve with respect to MCS-12 scores after surgery ( > .05), and those with leg pain-dominant symptoms (LPD group) had greater delta MCS-12 scores ( = .046) and greater recovery rates ( = .035). Multiple linear regression did not find LPD to be an independent predictor of PCS-12 or ODI scores.

Conclusion: Patients undergoing lumbar decompression surgery and leg pain-dominant symptoms noted a greater improvement in MCS-12 scores; however, there were no differences in PCS-12 or ODI scores.

Level Of Evidence: 3.

Clinical Relevance: Patients undergoing lumbar decompression surgery demonstrate no major clinically significant differences when split up by pain-dominance groups.
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http://dx.doi.org/10.14444/8100DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8375699PMC
August 2021

Update on Upper Cervical Injury Classifications: The New AO Upper Cervical Spine Classification System.

Clin Spine Surg 2021 Jul 7. Epub 2021 Jul 7.

Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA Department of Orthopaedics, Trauma and Spine Surgery, Ganga Hospital, Coimbatore, Tamil Nadu, India Spine Service, Orthopaedic Department, Sonnenhofspital, Bern, Switzerland University Medical Center, Utrecht, The Netherlands Center for Spine Surgery and Neurotraumatology, BG Unfallklinik Frankfurt am Main, Frankfurt Center for Spinal Surgery, Malteser Waldkrankenhaus St. Marien, Erlangen Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany.

The upper cervical spine accounts for the largest proportion of cervical range of motion afforded by a complex system of bony morphology and ligamentous stability. Its unique anatomy, however, also makes it particularly vulnerable during both low and high energy trauma. Trauma to this area, referred to as upper cervical spine trauma, can disrupt the stability of the upper cervical spine and result in a wide spectrum of injury. Numerous upper cervical injury classification systems have been proposed, each of which have distinct limitations and drawbacks that have prevented their universal adoption. In this article, we provide an overview of previous classifications, with an emphasis on the development of the new AO Spine Upper Cervical Classification System (AO Spine UCCS).
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http://dx.doi.org/10.1097/BSD.0000000000001215DOI Listing
July 2021

Timing of Preoperative Surgical Antibiotic Prophylaxis After Primary One-Level to Three-Level Lumbar Fusion.

World Neurosurg 2021 Sep 3;153:e349-e358. Epub 2021 Jul 3.

Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

Objective: The purpose of this study was to examine the relationship between timing of preoperative surgical antibiotic prophylaxis and postoperative surgical site infections (SSIs) among patients with 1-level to 3-level lumbar fusion.

Methods: Patients having undergone a primary 1-level to 3-level lumbar fusion at a single institution were allocated into 5 groups based on the time from preoperative antibiotic administration to incision (group A, 0-15 minutes; group B, 16-30 minutes; group C, 31-45 minutes; group D, 46-60 minutes; and group E, 61+ minutes). Timing of antibiotic administration as a continuous variable was also analyzed. All patients received irrigation with 3 L of normal saline containing bacitracin as well as local administration of vancomycin powder. SSIs were identified by the definition set forth by the 2017 Centers for Disease Control and Prevention guidelines.

Results: Among 1131 patients, 27 (2.4%) were found to have an SSI. Compared with patients with antibiotic administration within 0-15 minutes before incision, patients with administration 61+ minutes before incision (group 4) had significantly higher odds of developing an SSI (P < 0.001). Patients had a 1.05-fold higher likelihood of infection for each additional minute delay of administration before incision (P < 0.001). Receiver operating characteristic analysis reported an area under the curve of 0.733 and 0.776 for time as a continuous and categorical variable, respectively. Age (P = 0.02), body mass index (P = 0.03), diabetes mellitus diagnosis (P = 0.04), and type of antibiotic (P = 0.004) were significant predictors of SSI.

Conclusions: Our results show that preoperative antibiotic administration beyond 1 hour in patients who have undergone lumbar fusion is associated with higher rates of SSI.
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http://dx.doi.org/10.1016/j.wneu.2021.06.112DOI Listing
September 2021

A Randomized Controlled Trial of Early versus Late Surgical Decompression for Thoracic and Thoracolumbar Spinal Cord Injury in 73 Patients.

Neurotrauma Rep 2020 18;1(1):78-87. Epub 2020 Sep 18.

Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran.

Convincing clinical evidence exists to support early surgical decompression in the setting of cervical spinal cord injury (SCI). However, clinical evidence on the effect of early surgery in patients with thoracic and thoracolumbar (from T1 to L1 [T1-L1]) SCI is lacking and a critical knowledge gap remains. This randomized controlled trial (RCT) sought to evaluate the safety and efficacy of early (<24 h) compared with late (24-72 h) decompressive surgery after T1-L1 SCI. From 2010 to 2018, patients (≥16 years of age) with acute T1-L1 SCI presenting to a single trauma center were randomized to receive either early (<24 h) or late (24-72 h) surgical decompression. The primary outcome was an ordinal change in American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade at 12-month follow-up. Secondary outcomes included complications and change in ASIA motor score (AMS) at 12 months. Outcome assessors were blinded to treatment assignment. Of 73 individuals whose treatment followed the study protocol, 37 received early surgery and 36 underwent late surgery. The mean age was 29.74 ± 11.4 years. In the early group 45.9% of patients and in the late group 33.3% of patients had a ≥1-grade improvement in AIS (odds ratio [OR] 1.70, 95% confidence interval [CI]: 0.66-4.39,  = 0.271); significantly more patients in the early (24.3%) than late (5.6%) surgery group had a ≥2-grade improvement in AIS (OR 5.46, 95% CI: 1.09-27.38,  = 0.025). There was no statistically significant difference in the secondary outcome measures. Surgical decompression within 24 h of acute traumatic T1-L1 SCI is safe and is associated with improved neurological outcome, defined as at least a 2-grade improvement in AIS at 12 months.
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http://dx.doi.org/10.1089/neur.2020.0027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8240887PMC
September 2020

Evidence-based Recommendations for Spine Surgery.

Spine (Phila Pa 1976) 2021 Jul;46(14):975-982

Department of Orthopaedic Surgery, Bone and Joint Institute at Hartford Hospital, and Orthopaedic Associates of Hartford, Hartford, CT.

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http://dx.doi.org/10.1097/BRS.0000000000004091DOI Listing
July 2021

A Formula for a Study That Will Change Spine Practice: Research Fundamentals + Hard Work.

Spine (Phila Pa 1976) 2021 Jul;46(14):973-974

Departments of Orthopedic Surgery and Neurological Surgery, Thomas Jefferson University and The Rothman Institute, Philadelphia, PA.

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http://dx.doi.org/10.1097/BRS.0000000000004090DOI Listing
July 2021

Postoperative Glycemic Variability and Adverse Outcomes After Posterior Cervical Fusion.

J Am Acad Orthop Surg 2021 Jul;29(13):580-588

From the Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA.

Introduction: Posterior cervical decompression and fusion (PCDF) is a procedure commonly performed to help alleviate symptoms and improve quality of life in patients experiencing cervical spondylotic myelopathy, multilevel stenosis, and cervical deformity. Although various risk factors have been linked to adverse outcomes in patients after PCDF, this is the first study that specifically explores postoperative glycemic variability and its association with adverse outcomes.

Methods: A retrospective cohort study was conducted with a total of 264 patients after PCDF procedures that had available postoperative blood glucose measurements. Patients were divided into tertiles based on their coefficient of variation as an indicator of glycemic variability. Outcomes measured included inpatient complications, length of stay (LOS), 90-day readmission, revision, and surgical site infection rates.

Results: Results showed a significant difference in glycemic variability among tertiles with respect to LOS (P = 0.01). The average LOS for the first, second, and third tertiles was 3.90 (3.20, 4.59), 5.73 (4.45, 7.00), and 6.06 (4.89, 7.22), respectively. Logistic regression analysis showed significantly higher odds of readmission (odds ratio: 4.77; P = 0.03) and surgical site infections (odds ratio: 4.35; P = 0.04) in the high glycemic variability group compared with the low glycemic variability group within 90 days of surgery. No significant difference was noted among tertiles with respect to inpatient complications.

Discussion: This study establishes a relationship between postoperative glycemic variability and LOS, as well as 90-day readmission and surgical site infection rates after PCDF. Our results suggest that limiting fluctuations in blood glucose levels may curtail inpatient healthcare costs related to in-hospital stay. Although immediate postoperative glycemic variability is ultimately acceptable, before discharge, proper glucose management plans should be in place to help prevent adverse patient outcomes.
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http://dx.doi.org/10.5435/JAAOS-D-20-00126DOI Listing
July 2021

Postoperative Glycemic Variability and Adverse Outcomes After Posterior Cervical Fusion.

J Am Acad Orthop Surg 2021 Jul;29(13):580-588

From the Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA.

Introduction: Posterior cervical decompression and fusion (PCDF) is a procedure commonly performed to help alleviate symptoms and improve quality of life in patients experiencing cervical spondylotic myelopathy, multilevel stenosis, and cervical deformity. Although various risk factors have been linked to adverse outcomes in patients after PCDF, this is the first study that specifically explores postoperative glycemic variability and its association with adverse outcomes.

Methods: A retrospective cohort study was conducted with a total of 264 patients after PCDF procedures that had available postoperative blood glucose measurements. Patients were divided into tertiles based on their coefficient of variation as an indicator of glycemic variability. Outcomes measured included inpatient complications, length of stay (LOS), 90-day readmission, revision, and surgical site infection rates.

Results: Results showed a significant difference in glycemic variability among tertiles with respect to LOS (P = 0.01). The average LOS for the first, second, and third tertiles was 3.90 (3.20, 4.59), 5.73 (4.45, 7.00), and 6.06 (4.89, 7.22), respectively. Logistic regression analysis showed significantly higher odds of readmission (odds ratio: 4.77; P = 0.03) and surgical site infections (odds ratio: 4.35; P = 0.04) in the high glycemic variability group compared with the low glycemic variability group within 90 days of surgery. No significant difference was noted among tertiles with respect to inpatient complications.

Discussion: This study establishes a relationship between postoperative glycemic variability and LOS, as well as 90-day readmission and surgical site infection rates after PCDF. Our results suggest that limiting fluctuations in blood glucose levels may curtail inpatient healthcare costs related to in-hospital stay. Although immediate postoperative glycemic variability is ultimately acceptable, before discharge, proper glucose management plans should be in place to help prevent adverse patient outcomes.
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http://dx.doi.org/10.5435/JAAOS-D-20-00126DOI Listing
July 2021

Discharge Disposition and Clinical Outcomes After Spine Surgery.

Am J Med Qual 2021 Jun 10. Epub 2021 Jun 10.

Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA.

Objective: Spinal decompression with or without fusion is one of the most commonly performed procedures in spine surgery. However, there is limited evidence on the effect of discharge environment on outcomes after surgery. The purpose of this study is to identify the effects of discharge disposition setting on clinical outcomes after spine surgery.

Methods: Patients who underwent lumbar decompression, lumbar decompression and fusion, or posterior cervical decompression and fusion surgery were retrospectively identified. All clinical and demographic data were obtained from electronic health records. Surgical outcomes included wound complications, revision surgery, "30-day" readmission (0-30 d), and "90-day" readmission (31-90 d). Discharge disposition was stratified into home/self-care, acute inpatient rehabilitation, and subacute rehabilitation. Patient-reported outcome measures including VAS Back, VAS Leg, VAS Neck, VAS Arm, PCS-12 and MCS-12, ODI, and NDI were compared between patient discharge disposition settings using the Mann-Whitney U test. Pearson's chi-square analysis was used to assess for differences in wound complications, revision surgery, 30-day readmission, or 90-day readmission rates. Multivariate logistic regression incorporating age, sex, body mass index (BMI), Charlson Comorbidity Index (CCI), and discharge disposition was used to determine independent predictors of wound complications.

Results: A total of 637 patients were included in the study. A significant difference (P = 0.03) was found in wound complication based on discharge disposition, with subacute disposition having the highest proportion of wound complications (6.1%) and home disposition having the lowest (1.5%). There were no significant differences in the rates of revision surgery, 30-day readmission, or 90-day readmission between groups. Subacute rehabilitation (odds ratio: 3.67, P = 0.047) and CCI (odds ratio 1.49, P = 0.01) were independent predictors of wound complications. Significant improvement in PROMs was seen across all postacute discharge dispositions. Baseline (P = 0.02) and postoperative (P = 0.02) ODI were significantly higher among patients discharged to an acute facility (49.4 and 32.0, respectively) compared to home (42.2 and 20.0) or subacute (47.4 and 28.4) environments.

Conclusion: Subacute rehabilitation disposition and CCI are independent predictors of wound complications after spinal decompression surgery. Patients undergoing spine surgery have similar readmission and revision rates and experience similar clinical improvement across all postacute discharge dispositions.
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http://dx.doi.org/10.1097/01.JMQ.0000753240.14141.87DOI Listing
June 2021

The impact of data quality assurance and control solutions on the completeness, accuracy, and consistency of data in a national spinal cord injury registry of Iran (NSCIR-IR).

Spinal Cord Ser Cases 2021 Jun 10;7(1):51. Epub 2021 Jun 10.

Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran.

Study Design: Descriptive study.

Objective: This study aimed to develop and evaluate a systematic arrangement for improvement and monitoring of data quality of the National Spinal Cord (and Column) Injury Registry of Iran (NSCIR-IR)-a multicenter hospital-based registry.

Setting: SCI community in Iran.

Methods: Quality assurance and quality control were the primary objectives in improving overall quality of data that were considered in designing a paper-based and computerized case report. To prevent incorrect data entry, we implemented several validation algorithms, including 70 semantic rules, 18 syntactic rules, seven temporal rules, and 13 rules for acceptable value range. Qualified and trained staff members were also employed to review and identify any defect, inaccuracy, or inconsistency in the data to improve data quality. A set of functions were implemented in the software to cross-validate, and feedback on data was provided by reviewers and registrars.

Results: Socio-demographic data items were 100% complete, except for national ID and education level, which were 97% and 92.3% complete, respectively. Completeness of admission data and emergency medical services data were 100% except for arrival and transfer time (99.4%) and oxygen saturation (48.9%). Evaluation of data received from two centers located in Tehran proved to be 100% accurate following validation by quality reviewers. All data was also found to be 100% consistent.

Conclusions: This approach to quality assurance and consistency validation proved to be effective. Our solutions resulted in a significant decrease in the number of missing data.
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http://dx.doi.org/10.1038/s41394-020-00358-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8192950PMC
June 2021

SPINE20 A global advocacy group promoting evidence-based spine care of value.

Eur Spine J 2021 08 9;30(8):2091-2101. Epub 2021 Jun 9.

Ospedale Bambino Gesù, Roma, Italia.

Purpose: The Global Burden of Diseases (GBD) Studies have estimated that low back pain is one of the costliest ailments worldwide. Subsequent to GBD publications, leadership of the four largest global spine societies agreed to form SPINE20. This article introduces the concept of SPINE20, the recommendations, and the future of this global advocacy group linked to G20 annual summits.

Methods: The founders of SPINE20 advocacy group coordinated with G20 Saudi Arabia to conduct the SPINE20 summit in 2020. The summit was intended to promote evidence-based recommendations to use the most reliable information from high-level research. Eight areas of importance to mitigate spine disorders were identified through a voting process of the participating societies. Twelve recommendations were discussed and vetted.

Results: The areas of immediate concern were "Aging spine," "Future of spine care," "Spinal cord injuries," "Children and adolescent spine," "Spine-related disability," "Spine Educational Standards," "Patient safety," and "Burden on economy." Twelve recommendations were created and endorsed by 31/33 spine societies and 2 journals globally during a vetted process through the SPINE20.org website and during the virtual inaugural meeting November 10-11, 2020 held from the G20 platform.

Conclusions: This is the first time that international spine societies have joined to support actions to mitigate the burden of spine disorders across the globe. SPINE20 seeks to change awareness and treatment of spine pain by supporting local projects that implement value-based practices with healthcare policies that are culturally sensitive based on scientific evidence.
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http://dx.doi.org/10.1007/s00586-021-06890-5DOI Listing
August 2021
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