Publications by authors named "Steven Ludwig"

71 Publications

The Orthopaedic Match: Defining the Academic Profile of Successful Candidates.

J Am Acad Orthop Surg 2020 Nov 18. Epub 2020 Nov 18.

From the Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD (Ngaage, Xue, Benzel, Rawes, Rasko), the Medical College of Georgia, Augusta, GA (Xue), the Department of Orthopaedic Surgery, Howard University, Washington, DC (Andrews, Wilson), the Yorkshire and Humber Foundation School, Leeds, UK (Rawes), and the Department of Orthopaedic Surgery, University of Maryland School of Medicine, Baltimore, MD (Ludwig).

Background: Research productivity forms a vital part of the resident selection process and can markedly affect the chance of a successful match. Current reports regarding the publication record among prospective orthopaedic surgery residents are likely inaccurate. Potential applicants have a poor understanding of the strength of their research credentials in comparison to other candidates.

Methods: We identified matched applicants from the 2013 to 2017 orthopaedic surgery residency application cycles. We performed a bibliometric analysis of these residents using Scopus, PubMed, and Google Scholar to identify published articles and calculate the h-index of each applicant at the time of application. Details were collected on medical school, advanced degrees, publication type, first authorship, and article relatedness to orthopaedic surgery.

Results: We included 3,199 matched orthopaedic surgery applicants. At the time of application, the median h-index was 0, the median number of publications was 1, and 40% of successful candidates did not hold any publications. The h-index (R 0.08, P < 0.0001) and median number of publications of matched orthopaedic surgery residency candidates significantly increased (R 0.09, P < 0.0001) across application cycles. Furthermore, the proportion of matched applicants without publications at the time of application significantly decreased (R -0.90, P = 0.0350). Conversely, the percentage of articles first-authored by applicants decreased (R -0.96, P = 0.0093), but article relatedness to orthopaedic surgery remained constant (R 0.82, P = 0.0905). Strikingly, notable changes were observed in the type of articles published by successful applicants: the proportion of preclinical studies decreased (R -0.07, P = 0.0041), whereas clinical research articles increased (R 0.07, P = 0.0024).

Conclusion: The publication count held by successful orthopaedic surgery applicants is substantially lower than the nationally reported average. Matched orthopaedic surgery candidates demonstrate increasingly impressive research achievements each application cycle. However, increased academic productivity comes at the cost of reduced project responsibility and a shift toward faster-to-publish articles.
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http://dx.doi.org/10.5435/JAAOS-D-20-00727DOI Listing
November 2020

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

Patient Satisfaction After Discharge Is Discordant With Reported Inpatient Experience.

Orthopedics 2021 May-Jun;44(3):e427-e433. Epub 2021 May 1.

Patient satisfaction measures are commonly used to evaluate clinical performance. However, research on the correlation between patient satisfaction scores and actual patient experience is limited. This study aimed to determine the concordance between patient satisfaction reported as an inpatient and patient satisfaction reported after discharge. The study enrolled 231 adult orthopedic patients at least 48 hours after admission to an academic hospital. Study participants rated their overall inpatient experience on a scale of 0 to 10, followed by open-ended questions on their hospital experience. Participants were then randomized to a second survey by either phone or mail at 4 to 6 weeks after discharge. Statistical and qualitative techniques were used to assess concordance in satisfaction scores and the agreement and association between patient experiences and patient satisfaction scores. The median overall patient satisfaction scores were 9.5 as inpatients (interquartile range [IQR], 8-10) and 10 at follow-up (IQR, 8-10), with a poor concordance between the inpatient and follow-up satisfaction scores (ρ=0.28). This study raises concerns regarding the validity of patient satisfaction measures to accurately quantify inpatient experience and the limitations related to its modes of administration. The authors observed poor agreement between the reported experience as an inpatient and the recollection of the inpatient experience after discharge. [. 2021;44(3):e427-e433.].
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http://dx.doi.org/10.3928/01477447-20210415-01DOI Listing
July 2021

Improving Spine Models of Care.

JBJS Rev 2021 04;9(4):e20.00183

Departments of Orthopaedic Surgery (C.M.Y., H.M.L., J.D.K., and M.C.M.), Physical Medicine and Rehabilitation (S.I. and Z.I.), Anesthesiology (C.J.G.), and Neurosurgery (H.Z.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.2106/JBJS.RVW.20.00183DOI Listing
April 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

Impact of Preoperative Platelet Count on Bleeding Risk and Allogeneic Transfusion in Multilevel Spine Surgery.

Spine (Phila Pa 1976) 2021 Jan;46(1):E65-E72

University of Maryland School of Medicine, Baltimore, MD.

Study Design: This was an observational cohort study of patients receiving multilevel thoracic and lumbar spine surgery.

Objective: The aim of this study was to identify which patients are at high risk for allogeneic transfusion which may allow for better preoperative planning and employment of specific blood management strategies.

Summary Of Background Data: Multilevel posterior spine surgery is associated with a significant risk for major blood loss, and allogeneic blood transfusion is common in spine surgery.

Methods: A univariate logistic regression model was used to identify variables that were significantly associated with intraoperative allogeneic transfusion. A multivariate forward stepwise logistic regression model was then used to measure the adjusted association of these variables with intraoperative transfusion.

Results: Multilevel thoracic and lumbar spine surgery was performed in 921 patients. When stratifying patients by preoperative platelet count, patients with pre-operative thrombocytopenia and severe thrombocytopenia had a significantly higher rate of transfusion than those who were not thrombocytopenic. Furthermore, those with severe thrombocytopenia had a higher rate of red blood cells, fresh frozen plasma, and platelet transfusion than those with higher platelet counts. Multivariate logistic regression found that preoperative platelet count was the most significant contributor to transfusion, with a platelet count ≤100 having an adjusted odds ratio (OR) of transfusion of 4.88 (95% confidence interval [CI] 1.58-15.02, P = 0.006). Similarly, a platelet count between 101and 150 also doubled the risk of transfusion with an adjusted OR of 2.02 (95% CI 1.01-4.04, P = 0.047). The American Society of Anesthesiologists classification score increased the OR of transfusion by 2.5 times (OR = 2.52, 95% CI 1.54-4.13), whereas preoperative prothrombin time and age minimally increased the risk.

Conclusion: Preoperative thrombocytopenia significantly contributes to intraoperative transfusion in multilevel thoracic lumbar spine surgery. Identifying factors that may increase the risk for transfusion could be of great benefit in better preoperative counseling of patients and in reducing overall cost and postoperative complications by implementing strategies and techniques to reduce blood loss and blood transfusions.

Level Of Evidence: 2.
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http://dx.doi.org/10.1097/BRS.0000000000003737DOI 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

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

Change in rates of primary atlantoaxial spinal fusion surgeries in the United States (1993-2015).

J Neurosurg Spine 2020 Jan 24:1-7. Epub 2020 Jan 24.

Departments of1Orthopaedic Surgery and.

Objective: The objective of this study was to investigate revision burden and associated demographic and economic data for atlantoaxial (AA) fusion procedures in the US.

Methods: Patient data from the National Inpatient Sample (NIS) database for primary AA fusion were obtained from 1993 to 2015, and for revision AA fusion from 2006 to 2014 using ICD-9 procedure codes. Data from 2006 to 2014 were used in comparisons between primary and revision surgeries. National procedure rates, hospital costs/charges, length of stay (LOS), routine discharge, and mortality rates were investigated.

Results: Between 1993 and 2014, 52,011 patients underwent primary AA fusion. Over this period, there was a 111% increase in annual number of primary surgeries performed. An estimated 1372 patients underwent revision AA fusion between 2006 and 2014, and over this time period there was a 6% decrease in the number of revisions performed annually. The 65-84 year-old age group increased as a proportion of primary AA fusions in the US from 35.9% of all AA fusions in 1997 to 44.2% in 2015, an increase of 23%. The mean hospital cost for primary AA surgery increased 32% between 2006 and 2015, while the mean cost for revision AA surgery increased by 35% between 2006 and 2014. Between 2006 and 2014, the mean hospital charge for primary AA surgery increased by 67%; the mean charge for revision surgery over that same period increased by 57%. Between 2006 and 2014, the mean age for primary AA fusions was 60 years, while the mean age for revision AA fusions was 52 years. The mean LOS for both procedures decreased over the study period, with primary AA fusion decreasing by 31% and revision AA fusion decreasing by 24%. Revision burden decreased by 21% between 2006 and 2014 (mean 4.9%, range 3.2%-6.4%). The inpatient mortality rate for primary AA surgery decreased from 5.3% in 1993 to 2.2% in 2014.

Conclusions: The number of primary AA fusions between 2006 and 2014 increased 22%, while the number of revision procedures has decreased 6% over the same period. The revision burden decreased by 21%. The inpatient mortality rate decreased 62% (1993-2014) to 2.2%. The increased primary fusion rate, decreased revision burden, and decreased inpatient mortality determined in this study may suggest an improvement in the safety and success of primary AA fusion.
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http://dx.doi.org/10.3171/2019.11.SPINE19551DOI Listing
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 use of minimally invasive surgery in spine trauma: a review of concepts.

J Spine Surg 2019 Jun;5(Suppl 1):S91-S100

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

Traumatic injuries to the spine can be common in the setting of blunt trauma and delayed diagnosis can have a deleterious effect on patients' health. The goals of treatment in managing spine trauma are prevention of neurological injury, providing stability to the spine, and correcting post-traumatic deformity. Minimally invasive spine surgery (MISS) techniques are an alternative to open spine surgery for treatment of spine fractures. MISS is also a viable treatment in the setting of damage control orthopedics, when patients with multiple traumatic injuries may be unable to tolerate a traditional open approach. MISS techniques have been used in the treatment of unstable fractures with or without spinal cord injury, flexion and extension-distraction injuries, and unstable sacral fractures. Traditional open surgeries have been associated with increased blood loss, longer operative times, and a higher risk for surgical site infection (SSI). MISS techniques have the potential to reduce open approach-associated morbidity, and improve postoperative care and rehabilitation. MISS techniques for spine trauma are an indispensable option in the treatment armamentarium of spine surgeons.
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http://dx.doi.org/10.21037/jss.2019.04.13DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6626750PMC
June 2019

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

Perineal and Radicular Pain Caused by Contralateral Sacral Nerve Root Schwannoma: Case Report and Review of Literature.

World Neurosurg 2019 Sep 14;129:210-215. Epub 2019 Jun 14.

Department of Orthopedics, University of Maryland School of Medicine, Baltimore, Maryland, USA. Electronic address:

Background: Sacral schwannomas are very rare nerve sheath tumors. Patients usually present with a variety of nonspecific symptoms, which often lead to a delay in diagnosis. Although most schwannomas are benign, they present surgical challenges owing to their proximity to neurologic and other anatomic structures.

Case Description: This 58-year-old female presented with a 2-month old history of left-sided perineal and radicular pain secondary to a right S2 sacral nerve root schwannoma. The sacral mass demonstrated homogenous enhancement with cystic changes in a T2-weighted magnetic resonance imaging sequence. The patient underwent S1-S3 laminectomy and tumor excision through a posterior surgical approach. Intraoperative monitoring was used to distinguish nonfunctional tissue during tumor resection. The patient had an unremarkable postoperative course.

Conclusions: Sacral schwannomas can present with a variety of nonspecific symptoms. They pose unique challenges given their location, size, and involvement of surrounding structures. Complete surgical resection is the main goal of sacral schwannoma treatment. A combined anterior-posterior surgical approach and a multidisciplinary surgical team are associated with improved outcomes.
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http://dx.doi.org/10.1016/j.wneu.2019.06.012DOI Listing
September 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

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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http://dx.doi.org/10.1016/j.spinee.2018.09.002DOI Listing
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

Utilization of intraoperative neuromonitoring throughout the United States over a recent decade: an analysis of the nationwide inpatient sample.

J Spine Surg 2018 Jun;4(2):211-219

Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA.

Background: To identify temporal changes to the demographics and utilization of intraoperative neuromonitoring (IONM) throughout the United States (U.S.).

Methods: The National Inpatient Sample (NIS) database was queried for IONM of central and peripheral nervous electrical activity (ICD-9-CM 00.94) between 2008 and 2014. The NIS database represents a 20% sample of discharges from U.S. Hospitals, weighted to provide national estimates. Demographic and economic data were obtained which included the annual number of surgeries, age, sex, insurance type, location, and frequency of routine discharge.

Results: The estimated use of IONM of central and peripheral nervous electrical activity increased 296%, from 31,762 cases in 2008 to 125,835 cases in 2014. Based on payer type, privately insured patients (45.0%), rather than Medicare (36.8%) or Medicaid patients (9.2%), were more likely to undergo IONM during spinal procedures. When stratifying by median income for patient zip code, there was a substantial difference in the rates of IONM between low (19.9%) and high-income groups (78.1%). IONM was significantly more likely to be utilized at urban teaching hospitals (72.9%) rather than nonteaching hospitals (25.0%) or rural centers (2.2%).

Conclusions: Over the last decade, there has been a massive increase of 296% in utilization of IONM during spine surgery. This is likely due to its proven benefit in reducing neurologic morbidity in spinal deformity surgery, while introducing minimal additional risk. While IONM may improve patient care, it is still rather isolated to teaching hospitals and patients from higher income zip codes.
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http://dx.doi.org/10.21037/jss.2018.04.05DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6046319PMC
June 2018

Five-year results of a clinical pilot study utilizing a pedicle-lengthening osteotomy for the treatment of lumbar spinal stenosis.

J Neurosurg Spine 2018 Sep 1;29(3):241-249. Epub 2018 Jun 1.

3Department of Orthopaedics, Thomas Jefferson University/Rothman Institute, Philadelphia, Pennsylvania.

OBJECTIVE Lumbar spinal stenosis (LSS) is a common condition that leads to significant disability, particularly in the elderly. Current therapeutic options have certain drawbacks. This study evaluates the 5-year clinical and radiographic results of a minimally invasive pedicle-lengthening osteotomy (PLO) for symptomatic LSS. METHODS A prospective, single-arm, clinical pilot study was conducted involving 20 patients (mean age 61.7 years) with symptomatic LSS treated by a PLO procedure at 1 or 2 lumbar levels. All patients had symptoms of neurogenic claudication or radiculopathy secondary to LSS, and had not improved after a minimum 6-month course of nonoperative treatment. Eleven patients had a Meyerding grade I degenerative spondylolisthesis in addition to LSS. Clinical outcomes were measured using the Oswestry Disability Index, Zürich Claudication Questionnaire, 12-Item Short Form Health Survey, and a visual analog scale for back and leg pain. Procedural variables, neurological outcomes, adverse events, and radiological imaging (plain radiographs and CT scans) were collected at the 1.5-, 3-, 6-, 9-, 12-, 24-, and 60-month time points. RESULTS The PLOs were performed through percutaneous incisions, with minimal blood loss in all cases. There were no operative complications. Four adverse events occurred during the follow-up period. Statistically significant improvement was observed in each of the outcome instruments and maintained over the 5-year follow-up period. Imaging studies, reviewed by an independent radiologist, showed no evidence of device subsidence, migration, breakage, or heterotopic ossification. Thin-slice CT scans documented healing of the osteotomy site in all patients at the 6-month time point and an increase of 115% in the mean cross-sectional area of the spinal canal. CONCLUSIONS Treatment of patients with symptomatic LSS with a PLO procedure provided substantial enlargement of the area of the spinal canal and favorable clinical results for both disease-specific and non-disease-specific outcome measures at all follow-up time points out to 5 years. Future research is needed to compare this technique to alternative therapies for LSS.
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http://dx.doi.org/10.3171/2017.11.SPINE16664DOI Listing
September 2018

Frequency and Acceptability of Adverse Events After Anterior Cervical Discectomy and Fusion: A Survey Study From the Cervical Spine Research Society.

Clin Spine Surg 2018 06;31(5):E270-E277

Division of Neurosurgery, Thomas Jefferson University, Philadelphia PA.

Purpose: Anterior cervical discectomy and fusion has a low but well-established profile of adverse events. The goal of this study was to gauge surgeon opinion regarding the frequency and acceptability of these events.

Methods: A 2-page survey was distributed to attendees at the 2015 Cervical Spine Research Society (CSRS) meeting. Respondents were asked to categorize 18 anterior cervical discectomy and fusion-related adverse events as either: "common and acceptable," "uncommon and acceptable," "uncommon and sometimes acceptable," or "uncommon and unacceptable." Results were compiled to generate the relative frequency of these responses for each complication. Responses for each complication event were also compared between respondents based on practice location (US vs. non-US), primary specialty (orthopedics vs. neurosurgery) and years in practice.

Results: Of 150 surveys distributed, 115 responses were received (76.7% response rate), with the majority of respondents found to be US-based (71.3%) orthopedic surgeons (82.6%). Wrong level surgery, esophageal injury, retained drain, and spinal cord injury were considered by most to be unacceptable and uncommon complications. Dysphagia and adjacent segment disease occurred most often, but were deemed acceptable complications. Although surgeon experience and primary specialty had little impact on responses, practice location was found to significantly influence responses for 12 of 18 complications, with non-US surgeons found to categorize events more toward the uncommon and unacceptable end of the spectrum as compared with US surgeons.

Conclusions: These results serve to aid communication and transparency within the field of spine surgery, and will help to inform future quality improvement and best practice initiatives.
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http://dx.doi.org/10.1097/BSD.0000000000000645DOI Listing
June 2018

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

Atlas Fractures: Diagnosis, Current Treatment Recommendations, and Implications for Elderly Patients.

Clin Spine Surg 2018 08;31(7):278-284

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

Fractures of the C1 vertebrae (atlas) are commonly the result of falls and other trauma, which cause hyperextension, or axial compression of the cervical spine. Although historically thought as a benign injury with lower neurological risks, current data suggests that this may not hold true for geriatric patients (aged 65 y and older) who may be predisposed to these fractures even after lower-energy trauma such as ground-level falls. Advancements in orthopedic trauma care has increased our diagnostic abilities to identify and manage patients with C1 fractures and other upper cervical spine trauma. However, there are no universal treatment guidelines based on level I trials. Current treatment ranges from nonoperative to operative management depending on fracture-pattern and integrity of the surrounding ligaments. Furthermore, in the elderly patients these fractures present a unique dilemma due to preexisting comorbidities and contraindications to various treatment modalities. C1 fractures warrant greater recognition to provide optimal treatment to patients and minimize the risk for developing complications. The goal of this review is to highlight the most updated treatment guidelines and to discuss the complications of both operative and nonoperative management of C1 fractures especially among the elderly patient population.
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http://dx.doi.org/10.1097/BSD.0000000000000631DOI Listing
August 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
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