Publications by authors named "Daniel Gelb"

73 Publications

Dural Tear Does not Increase the Rate of Venous Thromboembolic Disease in Patients Undergoing Elective Lumbar Decompression with Instrumented Fusion.

World Neurosurg 2021 Jul 29. Epub 2021 Jul 29.

Department of Orthopaedic Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA. Electronic address:

Objective: Evaluate if dural tears (DTs) are an indirect risk factor for venous thromboembolic disease through increased recumbency in patients undergoing elective lumbar decompression and instrumented fusion.

Methods: This was a retrospective cohort study of consecutive patients undergoing elective lumbar decompression and instrumented fusion at a single institution between 2016 and 2019. Patients were divided into cohorts: those who sustained a dural tear and those who did not. The cohorts were compared using Student's t-test or Wilcoxon Rank Sum for continuous variables and Fisher exact or chi-squared test for nominal variables.

Results: Six-hundred and eleven patients met inclusion criteria, among which 144 patients (23.6%) sustained a DT. The DT cohort tended to be older (63.6 vs. 60.6 years, P = 0.0052) and have more comorbidities (Charlson Comorbidity Index 2.75 vs. 2.35, P = 0.0056). There was no significant difference in the rate of symptomatic deep vein thrombosis (2.1% vs. 2.6%, P = 1.0) or pulmonary embolus (1.4% vs. 1.50%, P = 1.0). Intraoperatively, DT was associated with increased blood loss (754 mL vs. 512 mL, P < 0.0001), operative time (224 vs. 195 minutes, P < 0.0001), and rate of transfusion (19.4% vs. 9.4%, P = 0.0018). Postoperatively, DT was associated with increased time to ambulation (2.6 vs. 1.4 days, P < 0.0001), length of stay (5.8 vs. 4.0 days, P < 0.0001), and rate of discharge to rehab (38.9 vs. 25.3%, P = 0.0021).

Conclusions: While DTs during elective lumbar decompression and instrumentation led to later ambulation and longer hospital stays, the increased recumbency did not significantly increase the rate of symptomatic venous thromboembolic disease.
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http://dx.doi.org/10.1016/j.wneu.2021.07.107DOI Listing
July 2021

Effect of Surgical Setting on Cost and Hospital Reported Outcomes for Single-Level Anterior Cervical Discectomy and Fusion.

Int J Spine Surg 2021 Aug 15;15(4):701-709. Epub 2021 Jul 15.

Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland.

Background: Hospitals seek to reduce costs and improve patient outcomes by decreasing length of stay (LOS), 30-day all-cause readmissions, and preventable complications. We evaluated hospital-reported outcome measures for elective single-level anterior cervical discectomy and fusions (ACDFs) between tertiary (TH) and community hospitals (CH) to determine location-based differences in complications, LOS, and overall costs.

Methods: Patients undergoing elective single-level ACDF in a 1-year period were retrospectively reviewed from a physician-driven database from a single medical system consisting of 1 TH and 4 CHs. Adult patients who underwent elective single-level ACDF were included. Patients with trauma, tumor, prior cervical surgery, and infection were excluded. Outcomes measures included all-cause 30-day readmissions, preventable complications, LOS, and hospital costs.

Results: A total of 301 patients (60 TH, 241 CH) were included. CHs had longer LOS (1.25 ± 0.50 versus 1.08 ± 0.28 days, = .01). There were no differences in complication and readmission rates between hospital settings. CH, orthopaedic subspecialty, female sex, and myelopathy were predictors for longer LOS. Overall, costs at the TH were significantly higher than at CHs ($17 171 versus $11 737; $ = 5434 ± 3996; < .0001). For CHs, the total costs of drugs, rooms, supplies, and therapy were significantly higher than at the TH. TH status, orthopaedic subspecialty, and myelopathy were associated with higher costs.

Conclusion: Patients undergoing single-level ACDFs at CHs had longer LOS, but similar complications and readmission rates as those at the TH. However, cost of ACDF was 1.5 times greater in the TH. To improve patient outcomes, optimize value, and reduce hospital costs, modifiable factors for elective ACDFs should be evaluated.

Level Of Evidence: 3.
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http://dx.doi.org/10.14444/8092DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8375676PMC
August 2021

Cardiac Surgery Outcomes: A Case for Increased Screening and Treatment of Obstructive Sleep Apnea.

Ann Thorac Surg 2021 May 1. Epub 2021 May 1.

Department of Surgery, Section of Cardiac Surgery, University of Vermont Medical Center, Burlington, VT.

Background: Due to the limited published information on complications that obstructive sleep apnea (OSA) patients experience during and after cardiac surgery, we are investigating OSA as a risk factor for post-operative outcomes.

Methods: This project utilized the Northern New England Cardiovascular Disease Study Group's data collected between 2011 and 2017 based on the Society of Thoracic Surgeons Adult Cardiac Surgery Database Data Collections form. A retrospective analysis of 1,555 patients with OSA and 10,450 patients without OSA, across 5 medical centers undergoing isolated CABG, isolated valve, combined CABG valve surgery was conducted. We used 1:1 nearest neighbor propensity score matching with no replacement to balance characteristics among patients with and without OSA.

Results: There was a statistically significant increased risk of post-operative pneumonia, increased length of total and post-operative stay, and time to initial extubation. Two outcomes trended towards significance: intra- and post-operative IABP use. Outcomes that failed to show statistical significance included: surgical site infection, atrial fibrillation cerebrovascular accident, permanent pacemaker placement, and blood products given. A chart review conducted on a subset of the study cohort revealed that more than 40% of OSA patients did not receive CPAP or BiPAP therapy post-operatively during their hospitalization.

Conclusions: Our study aligns with the literature in concluding that OSA has deleterious effects on post-operative outcomes of cardiac surgery patients. Further research to better stratify OSA patients by severity are still needed. Additionally, heightened awareness of the need to screen, diagnose, and properly treat patients for OSA is needed.
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http://dx.doi.org/10.1016/j.athoracsur.2021.04.046DOI Listing
May 2021

Comprehensive In Silico Evaluation of Accessory Rod Position, Rod Material and Diameter, Use of Cross-connectors, and Anterior Column Support in a Pedicle Subtraction Osteotomy Model: Part II: Effects on Lumbosacral Rod and Screw Strain.

Spine (Phila Pa 1976) 2021 Jan;46(1):E12-E22

Musculoskeletal Education and Research Center, A Division of Globus Medical, Inc., Audubon, PA.

Study Design: In silico finite element study.

Objective: The aim of this study was to evaluate effects of six construct factors on rod and screw strain at the lumbosacral junction in an in silico pedicle subtraction osteotomy (PSO) model: traditional inline and alternative Ames-Deviren-Gupta (ADG) multi-rod techniques, number of accessory rods (three-rod vs. four-rod), rod material (cobalt-chrome [CoCr] or stainless steel [SS] vs. titanium [Ti]), rod diameter (5.5 vs. 6.35 mm), and use of cross-connectors (CC), or anterior column support (ACS).

Summary Of Background Data: Implant failure and pseudoarthrosis at the lumbosacral junction following PSO are frequently reported. Clinicians may modulate reconstructs with multiple rods, rod position, rod material, and diameter, and with CC or ACS to reduce mechanical demand. An evaluation of these features' effects on rod and screw strains is lacking.

Methods: A finite element model (T12-S1) with intervertebral discs and ligaments was created and validated with cadaveric motion data. Lumbosacral rod and screw strain data were collected for 96 constructs across all six construct factors and normalized to the Ti 2-Rod control.

Results: The inline technique resulted in 12.5% to 51.3% more rod strain and decreased screw strain (88.3% to 95%) compared to ADG at the lumbosacral junction. An asymmetrical strain distribution was observed in the three-rod inline technique in comparison to four-rod, which was more evenly distributed. Regardless of construct features, rod strain was significantly decreased by rod material (CoCr > SS > Ti), and increasing rod diameter from 5.5 mm to 6.35 mm reduced strain by 9.9% to 22.1%. ACS resulted in significant reduction of rod (37.8%-59.8%) and screw strains (23.2%-65.8%).

Conclusion: Increasing rod diameter, using CoCr rods, and ACS were the most effective methods in reducing rod strain at the lumbosacral junction. The inline technique decreased screw strain and increased rod strain compared to ADG.

Level Of Evidence: N/A.
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http://dx.doi.org/10.1097/BRS.0000000000003720DOI Listing
January 2021

Comprehensive Evaluation of Accessory Rod Position, Rod Material and Diameter, Use of Cross-connectors, and Anterior Column Support in a Pedicle Subtraction Osteotomy Model: Part I: Effects on Apical Rod Strain: An In Vitro and In Silico Biomechanical Study.

Spine (Phila Pa 1976) 2021 Jan;46(1):E1-E11

Musculoskeletal Education and Research Center, A Division of Globus Medical, Inc., Audubon, PA.

Study Design: In silico finite element study.

Objective: The aim of this study was to evaluate the effect of six construct factors on apical rod strain in an in silico pedicle subtraction osteotomy (PSO) model: traditional inline and alternative Ames-Deviren-Gupta (ADG) multi-rod techniques, number of accessory rods (three- vs. four-rod), rod material (cobalt-chrome [CoCr] or stainless steel [SS] vs. titanium [Ti]), rod diameter (5.5 vs. 6.35 mm), and use of cross-connectors (CC), or anterior column support (ACS).

Summary Of Background Data: Rod fracture following lumbar PSO is frequently reported. Clinicians may modulate reconstructs with multiple rods, rod position, rod material and diameter, and with CC or ACS to reduce mechanical demand or rod contouring. A comprehensive evaluation of these features on rod strain is lacking.

Methods: A finite element model (T12-S1) with intervertebral discs and ligaments was created and validated with cadaveric motion data. Apical rod strain of primary and accessory rods was collected for 96 constructs across all six construct factors, and normalized to the Ti two-rod control.

Results: Regardless of construct features, CoCr and SS material reduced strain across all rods by 49.1% and 38.1%, respectively; increasing rod diameter from 5.5 mm to 6.35 mm rods reduced strain by 32.0%. Use of CC or lumbosacral ACS minimally affected apical rod strain (<2% difference from constructs without CC or ACS). Compared to the ADG technique, traditional inline reconstruction reduced primary rod strain by 32.2%; however, ADG primary rod required 14.2° less rod contouring. The inline technique produced asymmetrical loading between left and right rods, only when three rods were used.

Conclusion: The number of rods and position of accessory rods affected strain distribution on posterior fixation. Increasing rod diameter and using CoCr rods was most effective in reducing rod strain. Neither CC nor lumbosacral ACS affected apical rod strain.

Level Of Evidence: N/A.
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http://dx.doi.org/10.1097/BRS.0000000000003723DOI Listing
January 2021

Evaluation of Risk Factors for Postoperative Urinary Retention in Elective Thoracolumbar Spinal Fusion Patients.

Global Spine J 2021 Apr 26;11(3):338-344. Epub 2020 Feb 26.

12265University of Maryland School of Medicine, Baltimore, MD, USA.

Study Design: Retrospective case series.

Objectives: Postoperative urinary retention (POUR) represents a common postoperative complication of all elective surgeries. The aim of this study was to identify demographic, comorbid, and surgical factors risk factors for POUR in patients who underwent elective thoracolumbar spine fusion.

Methods: Following institutional review board approval, patients who underwent elective primary or revision thoracic and lumbar instrumented spinal fusion in a 2-year period in tertiary and academic institution were reviewed. Sex, age, BMI, preoperative diagnosis, comorbid conditions, benign prostatic hyperplasia, diabetes, primary or revision surgery status, narcotic use, and operative factors were collected and analyzed between patients with and without POUR.

Results: Of the 217 patients reviewed, 54 (24.9%) developed POUR. The average age for a patient with POUR was 67 ± 9, as opposed to 59 ± 10 for those without ( < .0001). Single-level fusions were associated with a 0% incidence of POUR, compared with 54.5% in 6 or more levels. The average hospital stay was increased by 1 day for those who had POUR (5.8 ± 3.3 vs 4.9 ± 3.9 days). There was no significant association with other demographic variables, comorbid conditions, or surgical factors.

Conclusions: POUR was a common complication in our patient cohort, with an incidence of 24.9%. Our findings demonstrate that patients who developed POUR are significantly older and have larger constructs. Patients who developed POUR also had longer in-hospital stays. Although our study supports other findings in the spine literature, more prospective data is needed to define diagnostic criteria of POUR as well as its management.
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http://dx.doi.org/10.1177/2192568220904681DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8013941PMC
April 2021

The Prevalence of Bacterial Infection in Patients Undergoing Elective ACDF for Degenerative Cervical Spine Conditions: A Prospective Cohort Study With Contaminant Control.

Global Spine J 2021 Jan 19;11(1):13-20. Epub 2019 Nov 19.

Department of Orthopaedics, 12264University of Maryland School of Medicine, Baltimore, MD, USA.

Study Design: Prospective cohort study.

Objectives: To determine the prevalence of bacterial infection, with the use of a contaminant control, in patients undergoing anterior cervical discectomy and fusion (ACDF).

Methods: After institutional review board approval, patients undergoing elective ACDF were prospectively enrolled. Samples of the longus colli muscle and disc tissue were obtained. The tissue was then homogenized, gram stained, and cultured in both aerobic and anaerobic medium. Patients were classified into 4 groups depending on culture results. Demographic, preoperative, and postoperative factors were evaluated.

Results: Ninety-six patients were enrolled, 41.7% were males with an average age of 54 ± 11 years and a body mass index of 29.7 ± 5.9 kg/m. Seventeen patients (17.7%) were considered true positives, having a negative control and positive disc culture. Otherwise, no significant differences in culture positivity was found between groups of patients. However, our results show that patients were more likely to have both control and disc negative than being a true positive (odds ratio = 6.2, 95% confidence interval = 2.5-14.6). was the most commonly identified bacteria. Two patients with disc positive cultures returned to the operating room secondary to pseudarthrosis; however, age, body mass index, prior spine surgery or injection, postoperative infection, and reoperations were not associated with culture results.

Conclusion: In our cohort, the prevalence of subclinical bacterial infection in patients undergoing ACDF was 17.7%. While our rates exclude patients with positive contaminant control, the possibility of contamination of disc cultures could not be entirely rejected. Overall, culture results did not have any influence on postoperative outcomes.
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http://dx.doi.org/10.1177/2192568219888179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7734272PMC
January 2021

Comparative effectiveness of revascularization strategies for early coronary artery disease: A multicenter analysis.

J Thorac Cardiovasc Surg 2020 May 20. Epub 2020 May 20.

Departments of Medicine and Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH.

Objectives: The goal of this analysis was to examine the comparative effectiveness of coronary artery bypass grafting versus percutaneous coronary intervention among patients aged less than 60 years.

Methods: We performed a multicenter, retrospective analysis of all cardiac revascularization procedures from 2005 to 2015 among 7 medical centers. Inclusion criteria were age less than 60 years and 70% stenosis or greater in 1 or more major coronary artery distribution. Exclusion criteria were left main 50% or greater, ST-elevation myocardial infarction, emergency status, and prior revascularization procedure. After applying inclusion and exclusion criteria, the final study cohort included 1945 patients who underwent cardiac surgery and 2938 patients who underwent percutaneous coronary intervention. The primary end point was all-cause mortality stratified by revascularization strategy. Secondary end points included stroke, repeat revascularization, and 30-day mortality. We used inverse probability weighting to balance differences among the groups.

Results: After adjustment, there was no significant difference in 30-day mortality (surgery: 0.8%; percutaneous coronary intervention: 0.7%, P = .86) for patients with multivessel disease. Patients undergoing surgery had a higher risk of stroke (1.3% [n = 25] vs 0.07% [n = 2], P < .001). Overall, surgery was associated with superior 10-year survival compared with percutaneous coronary intervention (hazard ratio, 0.71; 95% confidence interval, 0.57-0.88; P = .002). Repeat procedures occurred in 13.4% (n = 270) of the surgery group and 36.4% (n = 1068) of the percutaneous coronary intervention group, with both groups mostly undergoing percutaneous coronary intervention as their second operation. Accounting for death as a competing risk, at 10 years, surgery resulted in a lower cumulative incidence of repeat revascularization compared with percutaneous coronary intervention (subdistribution hazard ratio, 0.34; 95% confidence interval, 0.28-0.40; P < .001).

Conclusions: Among patients aged less than 60 years with 2-vessel disease that includes the left anterior descending or 3-vessel coronary artery disease, surgery was associated with greater long-term survival and decreased risk of repeat revascularization.
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http://dx.doi.org/10.1016/j.jtcvs.2020.03.164DOI Listing
May 2020

Effect of Surgical Setting on Hospital-Reported Outcomes for Elective Lumbar Spinal Procedures: Tertiary Versus Community Hospitals.

Global Spine J 2020 Jun 16;10(4):375-383. Epub 2019 May 16.

University of Maryland School of Medicine, Baltimore, MD, USA.

Study Design: Retrospective cohort study.

Objective: As hospital compensation becomes increasingly dependent on pay-for-performance and bundled payment compensation models, hospitals seek to reduce costs and increase quality. To our knowledge, no reported data compare these measures between hospital settings for elective lumbar procedures. The study compares hospital-reported outcomes and costs for elective lumbar procedures performed at a tertiary hospital (TH) versus community hospitals (CH) within a single health care system.

Methods: Retrospective review of a physician-maintained, prospectively collected database consisting of 1 TH and 4 CH for 3 common lumbar surgeries from 2015 to 2016. Patients undergoing primary elective microdiscectomy for disc herniation, laminectomy for spinal stenosis, and laminectomy with fusion for degenerative spondylolisthesis were included. Patients were excluded for traumatic, infectious, or malignant pathology. Comparing hospital settings, outcomes included length of stay (LOS), rates of 30-day readmissions, potentially preventable complications (PPC), and discharge to rehabilitation facility, and hospital costs.

Results: A total of 892 patients (n = 217 microdiscectomies, n = 302 laminectomies, and n = 373 laminectomy fusions) were included. The TH served a younger patient population with fewer comorbid conditions and a higher proportion of African Americans. The TH performed more decompressions ( < .001) per level fused; the CH performed more interbody fusions ( = .007). Cost of performing microdiscectomy ( < .001) and laminectomy ( = .014) was significantly higher at the TH, but there was no significant difference for laminectomy with fusion. In a multivariable stepwise linear regression analysis, the TH was significantly more expensive for single-level microdiscectomy ( < .001) and laminectomy with single-level fusion ( < .001), but trended toward significance for laminectomy without fusion ( = .052). No difference existed for PPC or readmissions rate. Patients undergoing laminectomy without fusion were discharged to a facility more often at the TH ( = .019).

Conclusions: We provide hospital-reported outcomes between a TH and CH. Significant differences in patient characteristics and surgical practices exist between surgical settings. Despite minimal differences in hospital-reported outcomes, the TH was significantly more expensive.
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http://dx.doi.org/10.1177/2192568219848666DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7222676PMC
June 2020

Radiographic Evaluation of Minimally Invasive Instrumentation and Fusion for Treating Unstable Spinal Column Injuries.

Global Spine J 2020 Apr 19;10(2):169-176. Epub 2019 Jun 19.

University of Maryland School of Medicine, Baltimore, MD, USA.

Study Design: Retrospective cohort.

Objective: Facet fusion in minimally invasive spine surgery (MISS) may reduce morbidity and promote long-term construct stability. The study compares the maintenance of correction of thoracolumbar (TL) trauma patients who underwent MISS with facet fusion (FF) and without facet fusion (WOFF) and evaluates instrumentation loosening and failure.

Methods: TL trauma patients who underwent MISS between 2006 and 2013 were identified and stratified into FF and WOFF groups. To evaluate progressive kyphosis and loss of correction, Cobb angles were measured at immediate postoperative, short-term, and long-term follow-up. Evidence of >2 mm of radiolucency on radiographs indicated screw loosening. If instrumentation was removed, postremoval kyphosis angle was obtained.

Results: Of the 80 patients, 24 were in FF and 56 were in WOFF group. Between immediate postoperative and short-term follow-up, kyphosis angle changed by 4.0° (standard error [SE] 1.3°) in the FF and by 3.0° (SE 0.4°) in the WOFF group. The change between immediate postoperative and long-term follow-up kyphosis angles was 3.4° (S.E 1.1°) and 5.2° (S.E 1.6°) degrees in the FF and WOFF groups, respectively. Facet fusion had no impact on the change in kyphosis at short term ( = .49) or long term ( = .39). The screw loosening rate was 20.5% for the 80 patients with short-term follow-up and 68.8% for the 16 patients with long-term follow-up. There was no difference in screw loosening rate. Fifteen patients underwent instrumentation removal-all from the FF group.

Conclusion: FF in MISS does not impact the correction achieved and maintenance of correction in patients with traumatic spine injuries.
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http://dx.doi.org/10.1177/2192568219856872DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7076603PMC
April 2020

Comparison of percutaneous minimally invasive versus open posterior spine surgery for fixation of thoracolumbar fractures: A retrospective matched cohort analysis.

J Orthop 2020 Mar-Apr;18:185-190. Epub 2019 Nov 27.

Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA.

Introduction: Percutaneous minimally invasive spine surgery (MISS) is a treatment option for thoracolumbar fractures and we aim to evaluate its outcomes.

Methods: A retrospective matched cohort study of all patients with thoracolumbar fractures treated with MISS or open posterior approach.

Results: We included 100 MISS and 155 open patients. After controlling for patient characteristics, our results statistically favor MISS in mean operative time, mean intraoperative blood loss, and number of patients requiring postoperative blood transfusions within 48 h.

Conclusions: Advantages of using MISS for treatment of thoracolumbar fractures are decreased operative time, decreased blood loss, and fewer patients requiring transfusions.
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http://dx.doi.org/10.1016/j.jor.2019.11.047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7000432PMC
November 2019

Minimizing Blood Loss in Spine Surgery.

Global Spine J 2020 Jan 6;10(1 Suppl):71S-83S. Epub 2020 Jan 6.

Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Study Design: Broad narrative review.

Objective: To review and summarize the current literature on guidelines, outcomes, techniques and indications surrounding multiple modalities of minimizing blood loss in spine surgery.

Methods: A thorough review of peer-reviewed literature was performed on the guidelines, outcomes, techniques, and indications for multiple modalities of minimizing blood loss in spine surgery.

Results: There is a large body of literature that provides a consensus on guidelines regarding the appropriate timing of discontinuation of anticoagulation, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal supplements prior to surgery. Additionally, there is a more heterogenous discussion the utility of preoperative autologous blood donation facilitated by erythropoietin and iron supplementation for healthy patients slated for procedures with high anticipated blood loss and for whom allogeneic transfusion is likely. Intraoperative maneuvers available to minimize blood loss include positioning and maintaining normothermia. Tranexamic acid (TXA), bipolar sealer electrocautery, and topical hemostatic agents, and hypotensive anesthesia (mean arterial pressure (MAP) <65 mm Hg) should be strongly considered in cases with larger exposures and higher anticipated blood loss. There is strong level 1 evidence for the use of TXA in spine surgery as it reduces the overall blood loss and transfusion requirements.

Conclusion: As the volume and complexity of spinal procedures rise, intraoperative blood loss management has become a pivotal topic of research within the field. There are many tools for minimizing blood loss in patients undergoing spine surgery. The current literature supports combining techniques to use a cost- effective multimodal approach to minimize blood loss in the perioperative period.
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http://dx.doi.org/10.1177/2192568219868475DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6947684PMC
January 2020

Effect of forced-air warming blanket position in elective lumbar spine surgery: Intraoperative body temperature and postoperative complications.

Surg Neurol Int 2019 29;10:229. Epub 2019 Nov 29.

Departments of Orthopaedic Surgery, University of Maryland Medical Center, Baltimore, Maryland, United States.

Background: Perioperative hypothermia is linked to multiple postoperative complications including increased surgical bleeding, surgical site infection, myocardial events, and increased length of hospital stay. The purpose of this study is to determine the effects of forced-air warming blanket position, above the shoulders versus under the trunk/legs, on intraoperative core body temperature and perioperative complications in elective lumbar spine surgery.

Methods: After IRB approval, patients were enrolled in a consecutive fashion and randomized to either upper body (Group I) or lower body (Group II) groups. Primary outcomes were intraoperative body temperature, incidence of hypothermia, postoperative complications, and infection. Secondary outcomes included blood loss, operative time, and length of stay.

Results: Seventy-four patients were included (Group I, 38; Group II, 36, mean age 60.7 years, 54% of male). Average patient follow-up was 69 ± 33.6 days in Group I and 67 ± 34.6 days in Group II. Average intraoperative body temperature was 35.7 in Group I and 35.8 in Group II ( = 0.27). Incidence of critical hypothermia (T < 35°C) was 18.4% and 11.1% in Groups I and II, respectively ( = 0.52). Incidence of mild hypothermia (T: 35°C-36°C) was 34.2% and 30.56% in Groups I and II, respectively ( = 0.81). Separately, pooled analysis comparing average body temperature and incidence infection demonstrated a relationship between mild hypothermia and infection ( = 0.03).

Conclusion: Compared to using a lower body Bair Hugger under the patient, using standard upper body Bair Hugger may be associated with increased surgical site infection. Given equivalent body warming, we recommend using the lower body Bair Hugger to avoid infection.
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http://dx.doi.org/10.25259/SNI_102_2019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6911670PMC
November 2019

The 30-Year Influence of a Regional Consortium on Quality Improvement in Cardiac Surgery.

Ann Thorac Surg 2020 07 23;110(1):63-69. Epub 2019 Nov 23.

Section of Cardiology, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.

Background: The Northern New England Cardiovascular Disease Study Group (NNECDSG) was founded in 1987 as a regional consortium to improve cardiovascular quality in Maine, New Hampshire, and Vermont. We sought to assess the longitudinal impact of the NNECDSG on quality and cost of coronary artery bypass grafting (CABG) during the past 30 years.

Methods: Patients undergoing isolated CABG at 5 medical centers from 1987-2017 were retrospectively reviewed (n = 67,942). They were divided into 4 time periods: 1987-1999 (n = 36,885), 2000-2005 (n = 14,606), 2006-2011(n = 8470), and 2012-2017 (n = 7981). The first period was the time the NNECDSG initiated a series of quality improvement initiatives including data feedback, quality improvement training, process mapping, and site visits.

Results: Throughout the 4 time intervals, there was a consistent decline in in-hospital mortality, from 3.4% to 1.8% despite an increase in predicted risk of mortality (P < .001), and a significant decline in in-hospital morbidity, including return to the operating room for bleeding, acute kidney injury, mediastinitis, and low output failure (P < .001). Median length of stay decreased from 7 to 5 days (P < .001), which translated into potential savings of $82,722,023. There was a decrease in use of red blood cells from 3.1 units to 2.6 units per patient in the most current time, which translated into potential savings of $1,985,456.

Conclusions: By using collaborative quality improvement initiatives, the NNECDSG has succeeded in significant, sustained improvements in quality and cost for CABG during the past 30 years. These data support the utility of a regional consortium in improving quality.
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http://dx.doi.org/10.1016/j.athoracsur.2019.10.008DOI Listing
July 2020

Delayed Diagnosis of Tandem Spinal Stenosis: A Retrospective Institutional Review.

Int J Spine Surg 2019 Jun 30;13(3):283-288. Epub 2019 Jun 30.

Department of Orthopaedics, University of Maryland Medical Center, Baltimore, Maryland.

Background: Tandem spinal stenosis (TSS) is defined as simultaneous spinal stenosis in the cervical, thoracic, and/or lumbar regions and may present with both upper and lower motor neuron symptoms, neurogenic claudication, and gait disturbance. Current literature has focused mainly on the prevalence of TSS and treatment methods, while the incidence of delayed TSS diagnosis is not well defined. The purpose of this study was to determine the incidence of delayed TSS diagnosis at our institution and describe the clinical characteristics commonly observed in their particular presentation.

Methods: Following institutional review board approval, an institutional billing database review was performed for patients who underwent a spinal decompression procedure between 2006 and 2016. Thirty-three patients who underwent decompression on 2 separate spinal regions within 1 year were included for review. Patients with delayed diagnosis of TSS following the first surgery were differentiated from those with preoperative diagnosis of TSS.

Results: TSS requiring surgical decompression occurred in 33 patients, with the incidence being 2.06% in this cohort. Fifteen patients received a delayed diagnosis after the first surgical decompression (45%) and were found to have a longer interval between decompressions (7.6 ± 2.1 months versus 4.01 ± 3 months, = .0004). Patients undergoing lumbar decompression as the initial procedure were more likely to have a delayed diagnosis of TSS (8 versus 2 patients, = .0200). The most common presentation of delayed TSS was pain and myelopathic symptoms that persisted after decompressive surgery.

Conclusion: TSS should remain within the differential diagnosis for patients at initial presentation of spinal stenosis. In addition, suspicion of TSS should be heightened if preoperative symptoms fail to expectedly improve following decompression even if overt myelopathic signs are not present.

Level Of Evidence: 4.
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http://dx.doi.org/10.14444/6038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6625710PMC
June 2019

The Utility of In-Hospital Postoperative Radiographs Following Surgical Treatment of Traumatic Thoracolumbar Injuries.

Clin Spine Surg 2019 07;32(6):E297-E302

Department of Orthopaedics, School of Medicine, University of Maryland, Baltimore, MD.

Study Design: A retrospective cohort study.

Objective: The objective of this study was to assess the utility of routine in-hospital postoperative radiographs for identifying hardware failure following surgical treatment of traumatic thoracolumbar (TL) injuries.

Background: Postoperative radiographs following spine surgery are considered standard of care despite a lack of evidence supporting their utility. Previous studies have concluded that postoperative radiographs following lumbar fusion for degenerative conditions have limited clinical value.

Materials And Methods: A retrospective chart review was performed on patients who underwent surgical treatment of traumatic TL injuries between December 2006 and October 2015 at a level I trauma center. Before discharge, postoperative upright anteroposterior and lateral radiographs were obtained and reviewed by 1 surgeon and 1 radiologist as per protocol. Patients who subsequently underwent revision surgery during their initial hospital stay were identified. These patients were further analyzed to identify the indications for surgery and determine if the results of the radiographs obtained led to the subsequent revision surgery.

Results: A total of 463 patients were identified who underwent surgical treatment following TL trauma. The rate of revision surgery during the initial hospitalization was 1.3% (6/463). Three patients underwent revision surgery due to worsening neurological status. One patient underwent reoperation because of advance imaging obtained for abdominal trauma. Two patients underwent revision surgery due to abnormal findings on postoperative radiographs. The overall sensitivity and specificity of routine postoperative radiographs was 33.3% and 100%, respectively.

Conclusions: In the absence of new clinical signs and symptoms, obtaining routine in-hospital postoperative radiographs following surgical treatment of TL injuries provides minimal value. Clinical assessment should help determine if additional imaging is indicated for the patient. Avoiding unnecessary inpatient tests such as routine postoperative radiograph may offer multitude of benefits including lowering patient radiation exposure, reducing health care costs and better allocation of hospital resources.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BSD.0000000000000826DOI Listing
July 2019

Decompression Versus Fusion for Grade I Degenerative Spondylolisthesis: A Meta-Analysis.

Global Spine J 2019 Apr 13;9(2):155-161. Epub 2018 Aug 13.

University of Maryland, Baltimore, MD, USA.

Study Design: Meta-analysis of evidence level I to IV studies.

Objective: To compare decompression alone versus decompression plus fusion in the treatment of grade I degenerative spondylolisthesis (DS).

Methods: Following established guidelines, we systematically reviewed 3 electronic databases to assess studies evaluating patients with grade I DS. We stratified all patients into 2 cohorts; the first cohort underwent a decompression-type surgery, and the second cohort underwent decompression plus fusion. We noted clinical outcomes, complications, reoperations, and surgical details such as blood loss. Descriptive statistics and random-effects models were used to determine the specified outcome metrics with 95% confidence intervals (CIs).

Results: In both cohorts, the pain (legs and lower back) significantly decreased and the physical component of the Short Form 36 showed better patient clinical outcomes. The decompression cohort had a 5.8% complication rate (95% CI = 1.7-2.1), and the decompression plus fusion cohort had an 8.3% complication rate (95% CI = 5.5-11.6). The reoperation rate was higher in the decompression-only cohort (8.5%; 95% CI = 2.9-17.0) compared with the decompression plus fusion cohort (4.9%; 95% CI = 2.5-7.9).

Conclusions: There does not appear to be any advantage of one procedure over the other. Patients undergoing decompression alone tended to be older with a higher percentage of leg pain, whereas patients additionally undergoing fusion tended to be younger with more lower back pain. The decompression-only cohort had fewer complications but a higher revision rate.
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http://dx.doi.org/10.1177/2192568218777476DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6448200PMC
April 2019

Can Liposomal Bupivacaine Be Safely Utilized in Elective Spine Surgery?

Global Spine J 2019 Apr 31;9(2):133-137. Epub 2018 Jul 31.

University of Maryland School of Medicine, Baltimore, MD, USA.

Study Design: Single-blinded prospective randomized control trial.

Objectives: To compare the incidence of adverse events (AEs) and hospital length of stay between patients who received liposomal bupivacaine (LB) versus a single saline injection, following posterior lumbar decompression and fusion surgery for degenerative spondylosis.

Methods: From 2015 to 2016, 59 patients undergoing posterior lumbar decompression and fusion surgery were prospectively enrolled and randomized to receive either 60 mL injection of 266 mg LB or 60 mL of 0.9% sterile saline, intraoperatively. Outcome measures included the incidence of postoperative AEs and hospital length of stay.

Results: The most common AEs in the treatment group were nausea (39.3%), emesis (18.1%), and hypotension (18.1%). Nausea (23%), constipation (19.2%), and urinary retention (15.3%) were most common in the control group. Patients who received LB had an increased risk of developing nausea (relative risk [RR] = 1.7; 95% confidence interval [CI] = 0.75-3.8), emesis (RR = 2.3; 95% CI = 0.51-10.7), and headaches (RR = 2.36; 95% CI = 0.26-21.4). Patients receiving LB had a decreased risk of developing constipation (RR = 0.78; 95% CI = 0.25-2.43), urinary retention (RR = 0.78; 95% CI = 0.21-2.85), and pruritus (RR = 0.78; 95% = 0.21-2.8) postoperatively. Relative risk values mentioned above failed to reach statistical significance. No significant difference in the hospital length of stay between both groups was found (3.9 vs 3.9 days; = .92).

Conclusion: Single-dose injections of LB to the surgical site prior to wound closure did not significantly increase or decrease the incidence or risk of developing AEs postoperatively. Furthermore, no significant difference was found in the hospital length of stay between both groups.
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http://dx.doi.org/10.1177/2192568218755684DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6448202PMC
April 2019

Tissue versus mechanical aortic valve replacement in younger patients: A multicenter analysis.

J Thorac Cardiovasc Surg 2019 12 1;158(6):1529-1538.e2. Epub 2019 Mar 1.

Section of Cardiac Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.

Objective: The goal of this study was to examine the long-term survival of patients between the ages of 50 and 65 years who underwent tissue versus mechanical aortic valve replacement (AVR) in a multicenter cohort.

Methods: A multicenter, retrospective analysis of all AVR patients (n = 9388) from 1991 to 2015 among 7 medical centers reporting to a prospectively maintained clinical registry was conducted. Inclusion criteria were: patients aged 50 to 65 years who underwent isolated AVR. Baseline comorbidities were balanced using inverse probability weighting for a study cohort of 1449 AVRs: 840 tissue and 609 mechanical. The primary end point of the analysis was all-cause mortality. Secondary end points included in-hospital morbidity, 30-day mortality, length of stay, and risk of reoperation.

Results: During the study period, there was a significant shift from mechanical to tissue valves (P < .001). There was no significant difference in major in-hospital morbidity, mortality, or length of hospitalization. Also, there was no significant difference in adjusted 15-year survival between mechanical versus tissue valves (hazard ratio, 0.87; 95% confidence interval [CI], 0.67-1.13; P = .29), although tissue valves were associated with a higher risk of reoperation with a cumulative incidence of 19.1% (95% CI, 14.4%-24.3%) versus 3.0% (95% CI, 1.7%-4.9%) for mechanical valves. The reoperative 30-day mortality rate was 2.4% (n = 2) for the series.

Conclusions: Among patients 50 to 65 years old who underwent AVR, there was no difference in adjusted long-term survival according to prosthesis type, but tissue valves were associated with a higher risk of reoperation.
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http://dx.doi.org/10.1016/j.jtcvs.2019.02.076DOI Listing
December 2019

The Efficacy of Liposomal Bupivacaine in Lumbar Spine Surgery.

Int J Spine Surg 2018 Aug 31;12(4):434-440. Epub 2018 Aug 31.

Department of Orthopaedics, University of Maryland Medical Center, University of Maryland, Baltimore, MD.

Background: Postoperative pain management in spine surgery holds unique challenges. The purpose of this study is to determine if the local anesthetic liposomal bupivacaine (LB) reduces the total opioid requirement in the first 3 days following posterior lumbar decompression and fusion (PLDF) surgery for degenerative spondylosis.

Methods: Fifty patients underwent PLDF surgery in a prospective randomized control pilot trial between August 2015 and October 2016 and were equally allocated to either a treatment (LB) or a control (saline) group. Assessments included the 72-hour postoperative opioid requirement normalized to 1 morphine milligram equivalent (MME), visual analog scale (VAS), and hospital length of stay.

Results: LB did not significantly alter the 72-hour postoperative opioid requirement compared to saline (11.6 vs. 13.4 MME, = .40). In a subgroup analysis, there was also no significant difference in opioid consumption among narcotic-naive patients with either LB or saline. Among narcotic tolerant patients, however, opioid consumption was higher with saline than LB (20.6 MME vs. 13.3 MME, = .048). Additionally, pre- and postoperative VAS scores and hospital length of stay were not significantly different with either LB or saline.

Conclusions: In the setting of PLDF surgery, LB injections did not significantly reduce the consumption of opioids in the first 3 postoperative days, nor did the hospital length of stay or VAS pain scores, compared to saline. However, LB could be beneficial in reducing the consumption of opioids in narcotic-tolerant populations.

Level Of Evidence: 2.
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http://dx.doi.org/10.14444/5052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6159630PMC
August 2018

Biomechanical evaluation of lumbar lateral interbody fusion for the treatment of adjacent segment disease.

Spine J 2019 03 7;19(3):545-551. Epub 2018 Sep 7.

University of Maryland Medical Center, Department of Orthopaedics, 110 S. Paca St, 6th Floor. Suite 300, Baltimore MD 21201-1642, USA. Electronic address:

Background Context: Adjacent segment disease (ASD) is a well-known complication after lumbar fusion. Lumbar lateral interbody fusion (LLIF) may provide an alternative method of treatment for ASD while avoiding the morbidity associated with revision surgery through a traditional posterior approach. This is the first biomechanical study to evaluate the stability of lateral-based constructs for treating ASD in existing multilevel fusion model.

Purpose: We aimed to evaluate the biomechanical stability of anterior column reconstruction through the less invasive lateral-based interbody techniques compared with traditional posterior spinal fusion for the treatment of ASD in existing multilevel fusion.

Study Design/setting: Cadaveric biomechanical study of laterally based interbody strategies for treating ASD.

Methods: Eighteen fresh-frozen cadaveric specimens were nondestructively loaded in flexion, extension, and lateral bending. The specimens were randomized into three different groups according to planned posterior spinal instrumented fusion (PSF): group 1: L5-S1, group 2: L4-S1, and group 3: L3-S1. In each group, ASD was considered the level cranial to the upper-instrumented vertebrae (UIV). After testing the intact spine, each specimen underwent PSF representing prior fusion in the ASD model. The adjacent segment for each specimen then underwent (1) Stand-alone LLIF, (2) LLIF + plate, (3) LLIF + single screw rod (SSR) anterior instrumentation, and (4) LLIF + traditional posterior extension of PSF. In all conditions, three-dimensional kinematics were tracked, and range of motion (ROM) was calculated for the comparisons.

Results: ROM results were expressed as a percentage of the intact spine ROM. LLIF effectively reduces ROM in all planes of ROM. Supplementation of LLIF with plate or SSR provides further stability as compared with stand-alone LLIF. Expansion of posterior instrumentation provides the most substantial stability in all planes of ROM (p <.05). All constructs demonstrated a consistent trend of reduction in ROM between all the groups in all bending motions.

Conclusions: This biomechanical study suggests potential promise in exploring LLIF as an alternative treatment of ASD but reinforces previous studies' findings that traditional expansion of posterior instrumentation provides the most biomechanically stable construct.
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March 2019

Outcomes of multilevel vertebrectomy for spondylodiscitis.

Spine J 2019 02 3;19(2):285-292. Epub 2018 Aug 3.

Department of Orthopaedic Surgery, Spine Division, University of Maryland School of Medicine. Electronic address:

Background Context: The incidence of pyogenic vertebral osteomyelitis (PVO) continues to increase in the United States, highlighting the need to recognize unique challenges presented by these cases and develop effective methods of surgical management. To date, no prior research has focused on the outcomes of PVO requiring two or more contiguous corpectomies.

Purpose: To describe our experience in the operative management of PVO in 56 consecutive patients who underwent multilevel corpectomies (≥2 vertebral bodies) via a combined approach.

Study Design/setting: Single institution retrospective cohort review between January 2002 and December 2015. All patients had been treated at an academic tertiary referral center by one of two fellowship-trained orthopedic spine surgeons.

Patient Sample: Patient records were cross-referenced with International Classification of Diseases osteomyelitis codes and paravertebral abscess code. Inclusion criteria for the study were patients within the cohort who had adequate medical records for review, a minimum patient age of 18 years, active vertebral osteomyelitis as an indication for surgical intervention, a minimum of 1-year radiographic follow-up, and surgical intervention that included at least two complete vertebral corpectomies. Subsequently, 56 patients met the inclusion criteria and were reviewed for this retrospective analysis.

Outcome Measures: Outcomes of interest were readmission and reoperation rates related to treatment of PVO, 30-day and 1-year mortality rates, radiographic outcomes, perioperative complications, infection control, and length of stay.

Methods: After obtaining approval from the Institutional Review Board, retrospective review was performed on records of all adults with PVO refractory to standard nonoperative treatment who underwent complete corpectomy of two or more contiguous vertebrae at a single institution between January 2002 and December 2015. This study was not funded, and no potential conflict of interest-associated biases were present.

Results: Fifty-six patients were identified (63% men; mean age 56.8 years; mean radiographic follow-up 2.8 years). Median length of stay was 13 days with nearly half readmitted (47%) after a median of 222.5 days after surgery. Twelve (22%) posterior revisions were required after a median 54 days for infection, painful or failed hardware, proximal junction kyphosis, adjacent level disease, or extension of the fusion. Thirty-day and 1-year mortality rates were 7.14% and 19.6%, respectively, with an infectious etiology as the most common cause of death.

Conclusions: Multilevel vertebral corpectomy for treatment of refractory vertebral osteomyelitis is associated with relatively high rates of complications and mortality compared with historical controls for 1 or 2 level procedures. We found clinical resolution and absence of complications requiring return to the operating room in 75% of patients when complete extirpation of the involved vertebrae is achieved. Our findings suggest multilevel anterior corpectomies with posterior stabilization may be a reasonable surgical option when approaching patients with complicated spondylodiscitis.
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http://dx.doi.org/10.1016/j.spinee.2018.06.361DOI Listing
February 2019

Low-Density Pedicle Screw Constructs for Adolescent Idiopathic Scoliosis: Evaluation of Effectiveness and Cost.

Global Spine J 2018 Apr 5;8(2):114-120. Epub 2017 Oct 5.

University of Maryland, Baltimore, MD, USA.

Study Design: Retrospective cohort study.

Objective: To determine whether a low-density (LD) screw construct can achieve curve correction similar to a high-density (HD) construct in adolescent scoliosis.

Methods: Patients treated operatively for idiopathic scoliosis between 2007 and 2011 were identified through a database review. A consistent LD screw construct was used. Radiographic assessment included percent correction of major and fractional lumbar curves, T5-T12 kyphosis, and angle of lowest instrumented vertebra (LIV). Costs were compared with HD constructs.

Results: Thirty-five patients were included in the analysis. Ages ranged from 12 to 19 years (mean = 14.9 years). Average screw density was 1.2 screws per level (range = 1.07-1.5 screws). Mean percent curve correction at latest follow-up: major curve, 66.9%; fractional lumbar curve, 63%. Average postoperative thoracic kyphosis: 29.5°. Mean LIV angle: 5.6°. Average construct cost was $14 871 per case compared with $23 840 per case if all levels had been instrumented with 2 screws, amounting to an average savings of $9000.

Conclusions: Our LD screw construct is among the lowest density constructs reported and achieves curve correction comparable to HD constructs at substantially lower cost.
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http://dx.doi.org/10.1177/2192568217735507DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5898679PMC
April 2018

Mortality Rates After Posterior C1-2 Fusion for Displaced Type II Odontoid Fractures in Octogenarians.

Spine (Phila Pa 1976) 2018 09;43(18):E1077-E1081

Department of Orthopedics; Spine Division, University of Maryland Medical Center.

Study Design: Retrospective cohort study OBJECTIVE.: To assess 30-day and 1-year mortality rates as well as the most common complications associated with posterior C1-2 fusion in an octogenarian cohort.

Summary Of Background Data: Treatment of unstable type II odontoid fractures in elderly patients can present challenges. Recent evidence indicates in patients older than 80 years, posterior C1-2 fusion results in improved survival as compared to other modes of treatment.

Methods: Retrospective analysis of 43 consecutive patients (25 female and 18 male; mean age 84.3 yr, range 80-89 yr; mean Charlson Comorbidity Index 1.4, (range 1-6); mean body mass index 24.8 ± 4.2 kg/m, who underwent posterior C1-C2 fusion for management of unstable type II odontoid fracture by four fellowship trained spine surgeons at a single institution between January 2006 to June 2016.

Results: Mean fracture displacement was 5.1 ± 3.6 mm and mean absolute value of angulation was 19.93° ± 12.93°. The most common complications were altered mental status (41.9%, n = 18), dysphagia (27.9%, n = 12) with 50% of those patients (6/12) requiring a feeding tube, and emergency reintubation (9.3%, n = 4). To the date of review completion, 25 of 43 patients expired (58.1%), median survival of 1.76 years from the date of surgery. Thirty-day and 1-year mortality rates were 2.3% and 18.6%, respectively. Patients who developed dysphagia were 14.5 times more likely to have expired at 1 year; dysphagia was also found to be significantly associated with degree of displacement. Fracture displacement was found to be associated with increased odds for 1-year mortality when accounting for age and requirement of a feeding tube.

Conclusion: Posterior C1-2 fusion results in acceptably low mortality rates in octogenarians with unstable type II odontoid fractures when compared to nonoperative management mortality rates in current literature. Initial fracture displacement is associated with higher mortality rate in this patient population.

Level Of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000002637DOI Listing
September 2018

Postoperative Deep Vein Thrombosis, Pulmonary Embolism, and Myocardial Infarction: Complications After Therapeutic Anticoagulation in the Patient With Spine Trauma.

Spine (Phila Pa 1976) 2018 07;43(13):E766-E772

Department of Orthopaedics.

Study Design: A retrospective review (2001-2014) was conducted using prospectively collected data at a level I trauma center.

Objective: We sought to determine the incidence and characteristics of complications occurring secondary to therapeutic anticoagulation in adult spine trauma patients.

Summary Of Background Data: Numerous studies have assessed prophylactic anticoagulation after spine surgery, but none has investigated the risks of therapeutic doses of anticoagulation for treatment of postoperative thromboembolic events.

Methods: Patients were included if they sustained a postoperative thromboembolic event (deep venous thrombosis, pulmonary embolism, or myocardial infarction). Patients were excluded if anticoagulation was subtherapeutic. Of 1712 patients, 62 who received therapeutic anticoagulation and 174 propensity-matched control patients who did not receive therapeutic anticoagulation were included in the study.

Results: Initial anticoagulation was obtained by heparin infusion (51%), low-molecular-weight heparin (LMWH, 46%), and warfarin (3%). Complications requiring unplanned reoperation occurred in 18% of anticoagulated patients and 10% of nonanticoagulated patients (P = 0.17). The reoperation rate after heparin infusion was 31% and after LMWH was 6.5% (P = 0.02). Epidural hematoma occurred in 3% and 1% of anticoagulated and nonanticoagulated patients, respectively. Multivariate logistic regression analysis of the two groups showed a trend toward increased risk of reoperation in the anticoagulation group. Analysis of the heparin infusion subgroup separate from the LMWH subgroup compared with the control group showed an increased risk of reoperation for any complication (odds ratio, 3.57; P = 0.01) and for bleeding complications (odds ratio, 43.1; P = 0.01).

Conclusion: This is the first study to quantify complications secondary to postoperative therapeutic anticoagulation in spine patients. Postoperative spine trauma patients who underwent therapeutic anticoagulation experienced an unplanned reoperation rate of 18%, including a 3% incidence of spinal epidural hematoma. Therapeutic anticoagulation using heparin infusion seems to drive the overall rate of reoperation (31%) compared with LMWH.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000002513DOI Listing
July 2018

Outcomes of lumbopelvic fixation in the treatment of complex sacral fractures using minimally invasive surgical techniques.

Spine J 2017 09 27;17(9):1238-1246. Epub 2017 Apr 27.

Department of Orthopaedics, University of Maryland, 110 South Paca St, 6th Floor, Suite 300, Baltimore, MD 21201, USA. Electronic address:

Background Context: Complex sacral fractures with vertical and anterior pelvic ring instability treated with traditional fixation methods are associated with high rates of failure and poor clinical outcomes. Supplemental lumbopelvic fixation (LPF) has been applied for additional stability to help with fracture union.

Purpose: The study aimed to determine whether minimally invasive LPF provides reliable fracture stability and acceptable complication rates in cases of complex sacral fractures.

Study Design/setting: This is a retrospective cohort study at a single level I trauma center.

Patient Sample: The sample includes 24 patients who underwent minimally invasive LPF for complex sacral fracture with or without associated pelvic ring injury.

Outcome Measures: Reoperation for all causes, loss of fixation, surgical time, transfusion requirements, length of hospital stay, postoperative day at mobilization, and mortality were evaluated.

Methods: Patient charts from 2008 to 2014 were reviewed. Of the 32 patients who underwent minimally invasive LPF for complex sacral fractures, 24 (12 male, 12 female) met all inclusion and exclusion criteria. Outcome measures were assessed with a retrospective chart review and radiographic review. The authors did not receive external funding for this study.

Results: Acute reoperation was 12%, and elective reoperation was 29%. Two (8%) patients returned to the operating room for infection, one (4.2%) required revision for instrumentation malposition, and seven (29%) underwent elective removal of instrumentation. No patient experienced failure of instrumentation or loss of correction. Average surgical time was 3.6 hours, blood loss was 180 mL, transfusion requirement was 2.1 units of packed red blood cells, and postoperative mobilization was on postoperative day 5. No mortalities occurred as a result of the minimally invasive LPF procedure.

Conclusions: Compared with historic reports of open LPF, our results demonstrate reliable maintenance of reduction and acceptable complication rates with minimally invasive LPF for complexsacral fractures. The benefits of minimally invasive LPF may be offset with increased elective reoperations for removal of instrumentation.
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September 2017

Does Lumbopelvic Fixation Add Stability? A Cadaveric Biomechanical Analysis of an Unstable Pelvic Fracture Model.

J Orthop Trauma 2017 Jan;31(1):37-46

*R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD; and †Globus Medical, Inc, Audubon, PA.

Objective: We sought to determine the role of lumbopelvic fixation (LPF) in the treatment of zone II sacral fractures with varying levels of sacral comminution combined with anterior pelvic ring (PR) instability. We also sought to determine the proximal extent of LPF necessary for adequate stabilization and the role of LPF in complex sacral fractures when only 1 transiliac-transsacral (TI-TS) screw is feasible.

Materials And Methods: Fifteen L4 to pelvis fresh-frozen cadaveric specimens were tested intact in flexion-extension (FE) and axial rotation (AR) in a bilateral stance gliding hip model. Two comminution severities were simulated through the sacral foramen using an oscillating saw, with either a single vertical fracture (small gap, 1 mm) or 2 vertical fractures 10 mm apart with the intermediary bone removed (large gap). We assessed sacral fracture zone (SZ), PR, and total lumbopelvic (TL) stability during FE and AR. The following variables were tested: (1) presence of transverse cross-connector, (2) presence of anterior plate, (3) extent of LPF (L4 vs. L5), (4) fracture gap size (small vs. large), (5) number of TI-TS screws (1 vs. 2).

Results: The transverse cross-connector and anterior plate significantly increased PR stability during AR (P = 0.02 and P = 0.01, respectively). Increased sacral comminution significantly affected SZ stability during FE (P = 0.01). Two versus 1 TI-TS screw in a large-gap model significantly affected TL stability (P = 0.04) and trended toward increased SZ stabilization during FE (P = 0.08). Addition of LPF (L4 and L5) significantly improved SZ and TL stability during AR and FE (P < 0.05). LPF in combination with TI-TS screws resulted in the least amount of motion across all 3 zones (SZ, PR, and TL) compared with all other constructs in both small-gap and large-gap models.

Conclusions: The role of LPF in the treatment of complex sacral fractures is supported, especially in the setting of sacral comminution. LPF with proximal fixation at L4 in a hybrid approach might be needed in highly comminuted cases and when only 1 TI-TS screw is feasible to obtain maximum biomechanical support across the fracture zone.
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http://dx.doi.org/10.1097/BOT.0000000000000703DOI Listing
January 2017

Facet Joint Violation During Percutaneous Pedicle Screw Placement: A Comparison of Two Techniques.

Spine (Phila Pa 1976) 2017 Aug;42(15):1189-1194

Department of Orthopaedics, University of Maryland, Baltimore, MD.

Study Design: A comparative study of facet joint violation (FJV) using two percutaneous surgical techniques.

Objective: To compare the rate of iatrogenic FJV and medial pedicle wall breach between two methods of percutaneous pedicle screw instrumentation in the thoracic and lumbar spine.

Summary Of Background Data: Variable iatrogenic damage to the facet joints has been reported to occur with percutaneous pedicle screw techniques, compared with the open approach, which has been associated with adjacent segment disease. Technical variations of percutaneous pedicle screw placement may pose different risks to the facet joint.

Methods: Attending spine surgeons percutaneously placed pedicle screws in seven human cadaveric spines from T2 to L5. At each level, screws were instrumented on one side using the 9 or 3 o'clock reference point of the pedicle on the posteroanterior view with a lateral-to-medial trajectory (LMT) and on the contralateral side using the center of the pedicle with an owl's eye trajectory (OET). Postoperative screw placement was assessed with computed tomography and then open cadaveric dissection. Outcome measures included FJV and medial pedicle wall breach.

Results: Overall, 17 of 105 screws placed with an LMT versus 49 of 105 screws placed with an OET violated or abutted the facet joint (P <0.0001). This significant difference was observed at the thoracic (T2-T10), thoracolumbar (T11-L1), and lumbar (L2-L5) levels (P = 0.003, 0.035, and 0.018, respectively). Medial pedicle wall breach occurred with 11 LMT screws and seven OET screws (P = 0.077), and no breach was considered critical.

Conclusion: A significantly higher FJV rate was observed using the OET versus the LMT in the thoracic, thoracolumbar, and lumbar spine. No statistically significant differences in medial pedicle wall breach occurred between the techniques. Thus, the LMT of minimally invasive pedicle screw fixation may reduce iatrogenic damage to the facet joints.

Level Of Evidence: 3.
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August 2017

A Comparison of Open and Percutaneous Techniques in the Operative Fixation of Spinal Fractures Associated with Ankylosing Spinal Disorders.

Int J Spine Surg 2016 7;10:23. Epub 2016 Jun 7.

Department of Orthopaedics, West Virginia University, Morgantown, WV.

Background: The operative care of patients with ankylosing spinal conditions such as ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) after a spine fracture is not well represented in the literature. This work seeks to determine the effect of minimally invasive techniques on patients with spinal fractures and ankylosing spinal conditions through a retrospective case-control analysis.

Methods: The operative logs from 1996-2013 of seven fellowship-trained spine surgeons from two academic, Level I trauma centers were reviewed for cases of operatively treated thoracic and lumbar spinal fractures in patients with ankylosing spinal disorders.

Results: A total of 38 patients with an ankylosing spinal condition and a spinal fracture were identified. The minimally invasive group demonstrated a statistically significant decrease in estimated blood loss, operative time, and need for transfusion when compared to either the hybrid or open group. There was no difference between the three subgroups in overall hospital stay or mortality.

Conclusions: Patients with ankylosing spinal conditions present unique challenges for operative fixation of spinal fractures. Minimally invasive techniques for internal fixation offer less blood loss, operative time, and need for transfusion compared to traditional techniques; however, no difference in hospital stay or mortality was reflected in this series of patients.

Level Of Evidence: 4.

Clinical Relevance: Ankylosing spinal disorders are increasingly common in an aging population.
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http://dx.doi.org/10.14444/3023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4943162PMC
July 2016

Pharmacological therapy for acute spinal cord injury.

Neurosurgery 2015 Mar;76 Suppl 1:S71-83

*Department of Clinical Neurosciences, University of Calgary Spine Program, Faculty of Medicine, University of Cal gary, Calgary, Alberta, Canada ‡Division of Neurological Surgery, and **Division of Neurological Surgery, Children's Hos pital of Alabama, University of Alabama at Birmingham, Birmingham, Alabama §Department of Neurosciences, Inova Health System, Falls Church, Virginia ¶Department of Neurosurgery, and #Department of Orthopaedics, University of Maryland, Baltimore, Maryland ‖Department of Neurosurgery, Emory University, Atlanta, Georgia ‡‡Iowa Spine & Brain Institute, University of Iowa, Waterloo/Iowa City, Iowa §§Division o Neurological Surgery, Barrow Neurologica Institute, Phoenix, Arizona.

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http://dx.doi.org/10.1227/01.neu.0000462080.04196.f7DOI Listing
March 2015
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