Modified Clavien-Dindo-Sink Classification System for operative complications in adult spine surgery.

OBJECTIVE: Currently there is no standardized mechanism to describe or compare complications in adult spine surgery. Thus, the purpose of the present study was to modify and validate the Clavien-Dindo-Sink complication classification system for applications in spine surgery. METHODS: The Clavien-Dindo-Sink complication classification system was evaluated and modified for spine surgery by four fellowship-trained spine surgeons using a consensus process. A distinct group of three fellowship-trained spine surgeons completed a randomized electronic survey grading 71 real-life clinical case scenarios. The survey was repeated 2 weeks after its initial completion. Fleiss' and Cohen's kappa (κ) statistics were used to evaluate interrater and intrarater reliabilities, respectively. RESULTS: Overall, interobserver reliability during the first and second rounds of grading was excellent with a κ of 0.847 (95% CI 0.785-0.908) and 0.852 (95% CI 0.791-0.913), respectively. In the first round, interrater reliability ranged from good to excellent with a κ of 0.778 for grade I (95% CI 0.644-0.912), 0.698 for grade II (95% CI 0.564-0.832), 0.861 for grade III (95% CI 0.727-0.996), 0.845 for grade IV-A (95% CI 0.711-0.979), 0.962 for grade IV-B (95% CI 0.828-1.097), and 0.960 for grade V (95% CI 0.826-1.094). Intraobserver reliability testing for all three independent observers was excellent with a κ of 0.971 (95% CI 0.944-0.999) for rater 1, 0.963 (95% CI 0.926-1.001) for rater 2, and 0.926 (95% CI 0.869-0.982) for rater 3. CONCLUSIONS: The Modified Clavien-Dindo-Sink Classification System demonstrates excellent interrater and intrarater reliability in adult spine surgery cases. This system provides a useful framework to better communicate the severity of spine-related complications.

Can Artificial Intelligence Improve the Readability of Patient Education Materials?

BACKGROUND: The recommended readability of online health education materials is at or below the sixth- to eighth-grade level. Nevertheless, more than a decade of research has demonstrated that most online education materials pertaining to orthopaedic surgery do not meet these recommendations. The repeated evidence of this limited progress underscores that unaddressed barriers exist to improving readability, such as the added time and cost associated with writing easily readable materials that cover complex topics. Freely available artificial intelligence (AI) platforms might facilitate the conversion of patient-education materials at scale, but to our knowledge, this has not been evaluated in orthopaedic surgery. QUESTIONS/PURPOSES: (1) Can a freely available AI dialogue platform rewrite orthopaedic patient education materials to reduce the required reading skill level from the high-school level to the sixth-grade level (which is approximately the median reading level in the United States)? (2) Were the converted materials accurate, and did they retain sufficient content detail to be informative as education materials for patients? METHODS: Descriptions of lumbar disc herniation, scoliosis, and spinal stenosis, as well as TKA and THA, were identified from educational materials published online by orthopaedic surgery specialty organizations and leading orthopaedic institutions. The descriptions were entered into an AI dialogue platform with the prompt "translate to fifth-grade reading level" to convert each group of text at or below the sixth-grade reading level. The fifth-grade reading level was selected to account for potential variation in how readability is defined by the AI platform, given that there are several widely used preexisting methods for defining readability levels. The Flesch Reading Ease score and Flesch-Kincaid grade level were determined for each description before and after AI conversion. The time to convert was also recorded. Each education material and its respective conversion was reviewed for factual inaccuracies, and each conversion was reviewed for its retention of sufficient detail for intended use as a patient education document. RESULTS: As presented to the public, the current descriptions of herniated lumbar disc, scoliosis, and stenosis had median (range) Flesch-Kincaid grade levels of 9.5 (9.1 to 10.5), 12.6 (10.8 to 15), and 10.9 (8 to 13.6), respectively. After conversion by the AI dialogue platform, the median Flesch-Kincaid grade level scores for herniated lumbar disc, scoliosis, and stenosis were 5.0 (3.3 to 8.2), 5.6 (4.1 to 7.3), and 6.9 (5 to 7.8), respectively. Similarly, descriptions of TKA and THA improved from 12.0 (11.2 to 13.5) to 6.3 (5.8 to 7.6) and from 11.6 (9.5 to 12.6) to 6.1 (5.4 to 7.1), respectively. The Flesch Reading Ease scores followed a similar trend. Seconds per sentence conversion was median 4.5 (3.3 to 4.9) and 4.5 (3.5 to 4.8) for spine conditions and arthroplasty, respectively. Evaluation of the materials that were converted for ease of reading still provided a sufficient level of nuance for patient education, and no factual errors or inaccuracies were identified. CONCLUSION: We found that a freely available AI dialogue platform can improve the reading accessibility of orthopaedic surgery online patient education materials to recommended levels quickly and effectively. Professional organizations and practices should determine whether their patient education materials exceed current recommended reading levels by using widely available measurement tools, and then apply an AI dialogue platform to facilitate converting their materials to more accessible levels if needed. Additional research is needed to determine whether this technology can be applied to additional materials meant to inform patients, such as surgical consent documents or postoperative instructions, and whether the methods presented here are applicable to non-English language materials.

Few Randomized Controlled Trials in Spine Surgery in the United States Include Sociodemographic Patient Data: A Systematic Review.

INTRODUCTION: The importance of sociodemographic factors such as race, education, and income on spine surgery outcomes has been well established, yet the representation of sociodemographic data within randomized controlled trials (RCTs) in spine literature remains undefined in the United States (U.S). METHODS: Medical literature was reviewed within PubMed for RCTs with "spine" in the title or abstract published within the last 8 years (2014 to 2021) in seven major spine journals. This yielded 128 results, and after application of inclusion criteria (RCTs concerning adult spine pathologies conducted in the U.S), 54 RCTs remained for analysis. Each article's journal of publication, year of publication, and spinal pathology was recorded. Pathologies included cervical degeneration, thoracolumbar degeneration, adult deformity, cervical trauma, and thoracolumbar trauma. Sociodemographic variables collected were race, ethnicity, insurance status, income, work status, and education. The Fisher's exact test was used to compare inclusion of sociodemographic data by journal, year, and spinal pathology. RESULTS: Sociodemographic data were included in the results and in any section of 57.4% (31/54) of RCTs. RCTs reported work status in 25.9% (14/54) of results and 38.9% (21/54) of RCTs included work status in any section. Income was included in the results and mentioned in any section in 13.0% (7/54) of RCTs. Insurance status was in the results or any section of 9.3% (5/54) and 18.5% (10/54) of RCTs, respectively. There was no association with inclusion of sociodemographic data within the results of RCTs as a factor of journal ( P = 0.337), year of publication ( P = 0.286), or spinal pathology ( P = 0.199). DISCUSSION: Despite evidence of the importance of sociodemographic factors on the natural history and treatment outcomes of myriad spine pathologies, this study identifies a surprising absence of sociodemographic data within contemporary RCTs in spine surgery. Failure to include sociodemographic factors in RCTs potentially bias the generalizability of outcome data.

Risk Factors For Prolonged Opioid Use After Spine Surgery.

STUDY DESIGN: Retrospective review. OBJECTIVE: Our purpose was to evaluate factors associated with increased risk of prolonged post-operative opioid pain medication usage following spine surgery, as well as identify the risk of various post-operative complications that may be associated with pre-operative opioid usage. METHODS: The MarketScan commercial claims and encounters database includes approximately 39 million patients per year. Patients undergoing cervical and lumbar spine surgery between the years 2005-2014 were identified using CPT codes. Pre-operative comorbidities including DSM-V mental health disorders, chronic pain, chronic regional pain syndrome (CRPS), obesity, tobacco use, medications, and diabetes were queried and documented. Patients who utilized opioids from 1-3 months prior to surgery were identified. This timeframe was chosen to exclude patients who had been prescribed pre- and post-operative narcotic medications up to 1 month prior to surgery. We utilized odds ratios (OR), 95% Confidence Intervals (CI), and regression analysis to determine factors that are associated with prolonged post-operative opioid use at 3 time intervals. RESULTS: 553,509 patients who underwent spine surgery during the 10-year period were identified. 34.9% of patients utilized opioids 1-3 months pre-operatively. 25% patients were still utilizing opioids at 6 weeks, 17.3% at 3 months, 12.7% at 6 months, and 9.0% at 1 year after surgery. Pre-operative opioid exposure was associated with increased likelihood of post-operative use at 6-12 weeks (OR 5.45, 95% CI 5.37-5.53), 3-6 months (OR 6.48, 95% CI 6.37-6.59), 6-12 months (OR 6.97, 95% CI 6.84-7.11), and >12 months (OR 7.12, 95% CI 6.96-7.29). Mental health diagnosis, tobacco usage, diagnosis of chronic pain or CRPS, and non-narcotic neuromodulatory medications yielded increased likelihood of prolonged post-op opioid usage. CONCLUSIONS: Pre-operative narcotic use and several patient comorbidities diagnoses are associated with prolonged post-operative opioid usage following spine surgery. Chronic opioid use, diagnosis of chronic pain, or use of non-narcotic neuromodulatory medications have the highest risk of prolonged post-operative opioid consumption. Patients using opiates pre-operatively did have an increased 30 and 90-day readmission risk, in addition to a number of serious post-operative complications. This data provides spine surgeons a number of variables to consider when determining post-operative analgesia strategies, and provides health systems, providers, and payers with information on complications associated with pre-operative opioid utilization.

Reported Events Associated With Spine Robots: An Analysis of the Food and Drug Administration's Manufacturer and User Facility Device Experience Database.

STUDY DESIGN: Cross-Sectional Analysis. OBJECTIVES: To summarize medical device reports (MDRs) between August 1, 2017 and November 30, 2021 relating to robot-assisted spine systems within the Manufacturer and User Facility Device Experience (MAUDE) database maintained by The Food and Drug Administration (FDA). METHODS: The MAUDE database was abstract for all MDRs relating to each FDA-approved robot-assisted spine system. Event descriptions were reviewed and characterized into specific event types. Outcome measures include specific robot-assisted spine systems and reported events as detailed by the MDRs. All data is de-identified and in compliance with the Health Insurance Portability and Accountability Act (HIPAA). RESULTS: There were 263 MDRs consisting of 265 reported events. Misplaced screws represented 61.5% (n = 163) of reported events. Of the 163 reported events, 57.1% (n = 93) described greater than 1 misplaced screw, 15.3% (n = 25) required return to the operating room, 8.6% (n = 14) resulted in neurologic injury, 4.3% (n = 7) resulted in dural tear, and 1.2% (n = 2) resulted in hemorrhage or bleeding. Reported events other than misplaced screws included system imprecision detected prior to screw placement (58/265, 21.9%), mechanical failure (23/265, 8.7%), and software failure (18/265, 6.8%). CONCLUSIONS: As more robot-assisted spine systems gain FDA approval and the adoption of these systems continues to grow, documenting and understanding the range of reported events associated with each "tool" is imperative to balancing patient safety with surgical innovation. This study of the MAUDE database provides a unique summary of reported events associated with robot-assisted spine systems that is not directly linked to a research setting.

To Use or Not Use Intraoperative Neuromonitoring: Utilization of Neuromonitoring During Spine Surgeries and Associated Conflicts of Interest, a Cross-Sectional Survey Study.

INTRODUCTION: There are no universal guidelines that dictate the indications for the use of intraoperative neuromonitoring (IONM) in spine surgery resulting in its variable use. The choice to use IONM has been both cited in malpractice lawsuits and insurance claims, but no data exist regarding surgeons' rationale for making this choice. The goal of this study was to assess (1) the use of certain IONM modalities during common spine surgeries, (2) surgeons' rationale for use of IONM, and (3) IONM practices and potential conflicts of interest associated with its use. METHODS: Respondents were asked to select each IONM modality they used during 20 different surgical scenarios within the spine followed by rating the importance of several reasons when selecting to use IONM. Finally, the occurrence of conflicts of interest, out-of-network billing, and cost were assessed. RESULTS: Approximately one-half (47%) of respondents who perform anterior cervical diskectomy and fusion/total disk arthroplasty for radiculopathy use IONM, opposed to 76% for myelopathy. The presence of cord compression and/or neurologic symptoms increased IONM use by approximately 30% during trauma cases. Medicolegal was the reason of highest importance when choosing to use IONM (7.4 ± 2.9; mean ± SD), followed by surgeon reassurance (6.2 ± 2.7; P < 0.0001 versus medicolegal) and belief it affects patient outcomes (5.2 ± 3.0; P = 0.004 versus reassurance). CONCLUSIONS: Although there is increasing use of IONM, this has not translated to an absolute requirement for every spine surgery. Surgeons are faced with opposing influences of the medicolegal system and insurance payers. Future guidelines on using IONM should not be absolute, but rather should consider the risks of each procedure, along with how patients and surgeons value these risks, in addition to the costs. The findings of this study should help to serve as a guide to surgeons, payers, and courts as contemporary, common practices for the use of IONM during spinal surgical scenarios.

Opioid Use, Perioperative Risks, and Associated Postoperative Complications in Foot and Ankle Surgery.

INTRODUCTION: Opioid abuse has become a national crisis. Published data demonstrate that patients undergoing foot and ankle surgery are left with excess narcotic medications postoperatively. The purpose of our study was to evaluate factors associated with prolonged postoperative opioid use following foot and ankle surgery and identify associations between preoperative opioid use and postoperative complications. METHODS: MarketScan commercial claims and encounters database was searched to identify foot and ankle patients. Preoperative comorbidities were queried and documented. Patients utilizing opioids 1 to 3 months prior to surgery were identified. Adjusted odds ratios and 95% CIs were calculated using multivariable logistic regression to determine associations between opioid use (preoperatively and postoperatively), readmission, and complications. RESULTS: A total of 112 893 patients were included in the study. Preoperative use had a statistically significant association with postoperative use out to 1 year. Tobacco use, chronic pain, mental health diagnosis, and nonopioid medications had a statistically significant association with postoperative use. Preoperative opioid use had a statistically significant association with readmission and postoperative complications. CONCLUSION: Our study found a number of factors associated with prolonged postoperative opioid use (preoperative use, tobacco use, chronic pain, mental health disorders, and certain nonopioid medications). We identified an association between preoperative opioid use and postoperative complications and readmission. LEVELS OF EVIDENCE: Prognostic Level IV Evidence.

Does Publication History Predict Future Publication Output in Orthopaedics?

Background The number of publications is widely used as a measure of academic productivity in the field of orthopaedics. How "productive" a physician is has a great influence on consideration for employment, compensation, and promotions. Predictors of potential high-output researchers would be of value to the orthopaedic department and university leadership for new faculty evaluation. Methods The study population included orthopaedic faculty from the top 10 orthopaedic institutions in the United States. Their names and the number of publications at each point in their training (medical school, residency, and fellowship) and early career (first five and 10 years following fellowship) along with a total number of publications to date were collected by using PubMed. Results Strong correlations were seen between publications during total training and publications output in the first five years following fellowship (rs =0.717, P<0.0001). However, no significant correlations were found comparing publications during each stage of training and the first 10 years following fellowship. A moderate positive correlation was found when comparing publications during medical school and residency output (rs =0.401, P<0.0001). Conclusions The data presented here may be utilized by department chairs during the evaluation of faculty and candidates to not interpret the number of publications during training and early career as a gauge of research interest and potential for future publications. Program directors may also use the only moderate correlation between publications in medical school and residency when evaluating applications as support of a more holistic review of applicants to determine research interest.

Nicotine Exposure Via Electronic Cigarettes Significantly Impedes Biomechanical Healing Properties of Tendon Healing in a Rat Model.

PURPOSE: To evaluate the biomechanical and histologic effects on Achilles tendon repair of inhaled combusted tobacco versus nicotine exposure via electronic cigarette versus a control group in a small-animal model (Sprague-Dawley rat). METHODS: Fifty-four Sprague-Dawley rats were randomized into 3 groups: combusted tobacco, e-cigarettes, or control. Experimental rats were exposed to research cigarettes or e-cigarette vapor in a smoking chamber for 4 weeks. Surgical transection and repair of the Achilles tendon were then completed, followed by 2 additional weeks of exposure. Achilles tendons were harvested, and biomechanical tensile testing was performed. Histologic evaluation was completed, including hematoxylin-eosin staining, trichrome staining, and immunohistochemistry analysis for type I and type III collagen. RESULTS: The control group showed the highest mean tensile load to failure, at 41.0 ± 10.4 N (range, 18.3-55.1 N); the cigarette cohort had the second highest mean, at 37.3 ± 11.1 N (range, 14.0-54.7 N); and finally, the vaping group had the lowest mean, at 32.3 ± 8.4 N (range, 17.8-45.1 N). One-way analysis of variance showed a significant difference in load to failure when comparing the control group with the e-cigarette group (P = .026). No statistical difference was detected between the control group and cigarette group (P = .35) or between the e-cigarette group and cigarette group (P = .23). Stiffness and qualitative histologic analysis showed no difference among groups. CONCLUSIONS: This investigation shows that in a rat model, nicotine exposure via e-cigarette significantly impedes the biomechanical healing properties of Achilles tendon surgical repair. CLINICAL RELEVANCE: The results indicate that although e-cigarettes are often used as a perceived "safer" alternative to smoking, their use may have a detrimental effect on tendon load to failure.

Preoperative Opioid Use Is Associated With Persistent Use, Readmission and Postoperative Complications After Arthroscopic Knee Surgery.

PURPOSE: To evaluate factors associated with prolonged opioid use after arthroscopic knee surgery and to identify associations between preoperative usage and postoperative complications. METHODS: The MarketScan commercial database was searched to identify patients who underwent arthroscopic knee surgery from 2005 to 2014 (based on Current Procedure Terminology code). Preoperative comorbidities including Diagnostic and Statistical Manual of Mental Disorders mental health disorders, chronic pain, chronic regional pain syndrome, obesity, tobacco use, non-narcotic medications and diabetes were queried and documented. Patients who filled opioid prescriptions 1 to 3 months before surgery were identified. Patients who filled opioid prescriptions after surgery were identified. Adjusted odds ratios and 95% confidence intervals were calculated using multivariable logistic regression analysis to determine factors associated with prolonged postoperative opioid use. RESULTS: In total, 1,012,486 patients who underwent arthroscopic knee surgery were identified, and we determined which of these patients were on preoperative opioids. Preoperative opioid usage was associated with a statistically significant increased risk of usage out to 1 year. There was a statistically significant association between postoperative usage and preoperative variables (mental health diagnosis, smokers, chronic pain, chronic regional pain syndrome, and use of non-narcotic medications). There was a statistically significant association between preoperative opioid use and 90-day readmission and postoperative complications. CONCLUSION: In this study, we found that patients taking opioids 1 to 3 months before arthroscopic knee surgery have increased risk of postoperative use. Additionally, chronic opioid use, chronic pain, or use of non-narcotic medications has the highest risk of postoperative opioid use. Finally, preoperative use was associated with an increased risk of 90-day readmission. EVIDENCE: Prognostic Level IV Evidence.

Spine Fixation Hardware: An Update.

OBJECTIVE. The purpose of this article is to provide a review of the imaging of spine fixation hardware. CONCLUSION. As the prevalence of neck and back pain continues to increase, so does the number of surgical procedures used to treat such pain. Accordingly, new techniques and hardware designs are used, and the hardware will be seen on postoperative imaging. It is critical that radiologists understand the appropriate imaging modalities for the assessment of spine fixation hardware, recognize the normal imaging appearance of such hardware, and be able to detect hardware-related complications.

Factors in Orthopaedic Residency Decision-making for Female Applicants: A Cross-sectional Study.

BACKGROUND: Orthopaedics continues to remain the medical specialty with the lowest sex diversity in the United States. Orthopaedic residency programs are highly motivated to attract the best female candidates in an effort to improve their program diversity, but no studies currently exist that examine the factors of highest importance to female applicants for orthopaedic residency selection. METHODS: A two-part survey was sent to female orthopaedic residents by e-mails available in the American Academy of Orthopaedic Surgery directory, residency program coordinators, Doximity, and institutional websites. The survey included 17 characteristics of residency programs that participants were asked to score for importance and then asked to rank their top five most influential factors when selecting an orthopaedic surgery residency. RESULTS: The most important factors included camaraderie among residents, happiness of current residents, variety/number of cases, fellowship placement, and early surgical/clinical experience, respectively. The least important factors included sex diversity of faculty and residents, number of female residents, concurrent fellows, number of female faculty geographic location near spouse, and finally, attitudes toward maternity leave. DISCUSSION: These data support the notion that efforts by orthopaedic residency programs to improve desirability for female applicants should focus on highlighting some of the more universal, nonsex-related factors such as the happiness and camaraderie among residents and the anticipated clinical experiences. This is opposed to showcasing features, such as maternity leave and number of current female faculty or residents, which would seemingly appeal to female applicants.

Factors in Residency Decision Making for Female Neurosurgery Applicants.

BACKGROUND: Neurosurgery remains a specialty with one of the largest gender gaps in the United States. Neurosurgery residency programs are highly motivated to attract the best female candidates in an effort to improve their program diversity, but no studies currently exist that examine the factors of highest importance to female applicants for neurosurgery residency selection. The purpose of this study was to determine factors that female neurosurgery residents used when selecting their residency. METHODS: A 2-part survey was sent to female neurosurgical residents by e-mails collected from the American Association of Neurological Surgeons directory and residency program websites. The survey asked participants to score 17 characteristics of residency programs in terms of importance and then asked them to rank their top 5 most influential factors when selecting a neurosurgery residency. RESULTS: The most important factors included variety/number of cases, camaraderie and happiness of current residents, early surgical/clinical experience, and academic reputation. The least important factors included gender diversity of faculty and residents, number of female residents, number of female faculty, and attitudes toward maternity leave. CONCLUSIONS: Efforts to increase female applicants in neurosurgery residency programs should focus on highlighting some more universal, non-gender-related factors, such as happiness and camaraderie among residents and anticipated clinical experiences, as opposed to showcasing features that would seemingly appeal to female applicants, such as maternity leave and number of current female faculty or residents.

Authorship and study characteristic trends in spine publications from years 2004 to 2017.

BACKGROUND: The goal of this study was to analyze the trends in authorship and study characteristics in Spine using two overlapping ten-year time periods: 2004-2014 and 2007-2017. To our knowledge, no other literature reports study characteristics and authorship in the same time period for spine that would allow for the assessment of confounding factors of trends. METHODS: Authorship and study characteristic data was collected from all scientific manuscripts published in Spine during the years of 2004, 2007, 2014, and 2017. Basic statistics and Kruskal-Wallis test were used to analyze the data. RESULTS: We found a significant increase in total number of authors (P<0.0001) without discrepancy of unequivocal increases in author degree type: MD/Equivalent (P≤0.0001), PhD/Doctorate (P=0.0017), Masters (P=0.0015), and Bachelors (P≤0.0001). We observed an increase in industry authorship (P≤0.0001), but without a significant increase in industry funding during the same time span. Increases in administration database studies (P≤0.0001) and economic/value studies (P≤0.0001) were also noted. A significant change in percentage of articles with trauma pathology (decrease, P<0.0001) and deformity (increase, P=0.0002) occurred. The number of multi-institutional studies increased (P≤0.0001), while no change in the number of multi-disciplinary studies. CONCLUSIONS: Increases in author number for spine articles over time are a result of a general increase in authors in all degree types, not just non-doctorate degrees. This may be potentially influenced by the increase in multi-institutional studies. From 2004-2017, higher percentages of articles focus on economics. An increase in industry authorship without a corresponding increase in funding suggests industry's more 'hands-on' approach to publication results from their funded studies.

Quantifying Dysfunction of the Lumbar Multifidus Muscle After Radiofrequency Neurotomy and Fusion Surgery: A Preliminary Study.

The multifidus is an important muscle for the active stabilization of the spine. Unfortunately, clinical procedures such as posterior lumbar fusion (PLF) and radio frequency neurotomy (RFN) cause injury to these muscles affecting their function. However, evaluating multifidus function using traditional biomechanical methods is challenging due to its unique anatomical features. The change in muscle shear modulus during contraction has been corrected to force generation for several skeletal muscles. Therefore, the change in shear modulus can be used to quantify muscle contraction. The objective of this study was to evaluate multifidus dysfunction by comparing changes in shear modulus during muscle contraction in healthy individuals and patients who received RFN and PLF in the lumbar spine. We used our recently developed protocol which consists of measuring changes of multifidus shear modulus at lying prone, sitting up, and sitting up with the arms lifted. In healthy individuals, the median multifidus shear modulus increased progressively from prone, sitting, and sitting with arms raised: 18.55 kPa, 27.14 kPa, and 38.45 kPa, respectively. A moderate increase in shear modulus for these body positions was observed in PLF patients: 9.81 kPa, 17.26 kPa, and 21.85 kPa. In RFN patients, the shear modulus remained relatively constant: 14.44 kPa, 16.57 kPa, and 17.26 kPa. Overall, RFN and PLF caused a reduction in the contraction of multifidus muscles. However, the contraction of multifidus muscle slightly increased during multifidus activation in PLF patients, while it did not change in RFN patients. These preliminary measurements suggest that the proposed protocol using SWE can provide important information about the function of individual spine muscles to guide the design and evaluation of postsurgical rehabilitation protocols.

External Orthopaedic Implants in the Magnetic Resonance Environment: Current Concepts and Controversies.

MRI provides diagnostic three-dimensional imaging and remains extremely important in the diagnosis and management of spinal trauma as well as other acute traumatic injuries, including those of the extremities. The American Society for Testing and Materials has created standards against which all implantable medical devices are tested to ensure safety in an MR environment. Most implantable passive orthopaedic devices can undergo MRI without consequence to the patient. However, the American Society for Testing and Materials has recently updated its terminology resulting in confusion among providers and institutions. Primary safety concerns are radiofrequency-induced heating and magnetically induced torque or displacement. These safety concerns have emerged as a recent source of debate, particularly regarding the imaging of patients with external fixation and cervical immobilization devices in place. Surveys have shown a lack of consensus among radiologists regarding this issue. Having an institutional protocol in place for the imaging of these patients streamlines the diagnosis and early stabilization of certain polytraumatized patients. The purpose of this review is to summarize the pertinent literature as well as the current industry recommendations regarding the safety of commonly used external fixation, cervical immobilization, and traction devices in the MR environment.

Changes in Shear Modulus of the Lumbar Multifidus Muscle During Different Body Positions.

Multifidus function is important for active stabilization of the spine, but it can be compromised in patients with chronic low back pain and other spine pathologies. Force production and strength of back muscles are often evaluated using isometric or isokinetic tests, which lack the ability to quantify multifidi contribution independent of the erector spinae and adjacent hip musculature. The objective of this study is to evaluate localized force production capability in multifidus muscle using ultrasound shear wave elastography (SWE) in healthy individuals. Three different body positions were considered: lying prone, sitting up, and sitting up with the right arm lifted. These positions were chosen to progressively increase multifidus contraction and to minimize body motion during measurements. Shear modulus was measured at the superficial and deeper layers of the multifidus. Repeatability and possible sources of error of the shear modulus measurements were analyzed. Multifidus shear modulus (median (interquartile range)) increased from prone, i.e., 16.15 (6.69) kPa, to sitting up, i.e., 27.28 (15.72) kPa, to sitting up with the right arm lifted position, i.e., 45.02 (25.27) kPa. Multifidi shear modulus in the deeper layer of the multifidi was lower than the superficial layer, suggesting lower muscle contraction. Intraclass correlation coefficients (ICCs) for evaluation of shear modulus by muscle layer were found to be excellent (ICC = 0.76-0.80). Results suggest that the proposed protocol could quantify local changes in spinal muscle function in healthy adults; further research in patients with spine pathology is warranted.

Sarcopenia Is Predictive of 1-Year Mortality After Acetabular Fractures in Elderly Patients.

OBJECTIVES: To determine whether sarcopenia is an independent predictor of mortality in geriatric acetabular fractures. DESIGN: Retrospective cohort. SETTING: American College of Surgeons Level I trauma center. PATIENTS/PARTICIPANTS: One hundred and forty-six patients over the age 60 with acetabular fractures treated at our institution over a 12-year period. MAIN OUTCOME MEASUREMENTS: The primary outcome was 1-year mortality, collected using the Social Security Death Index. We used the psoas:lumbar vertebral index (PLVI), calculated using the cross-sectional area of the L4 vertebral body and the left and right psoas muscles, to assess for sarcopenia. RESULTS: Using a multivariate logistic regression model, we found that low PLVI was associated with increased 1-year mortality (P = 0.046) when controlling for age, gender, Charlson Comorbidity Index, Injury Severity Score (ISS), smoking status, and associated pelvic ring injury. Increasing age and ISS also showed a relationship with 1-year mortality in this cohort (P < 0.001, P < 0.001, respectively). We defined sarcopenia as those patients in the lowest quartile of PLVI. The mortality rate of this cohort was 32.4%, compared with 11.0% in patients without sarcopenia (odds ratio 4.04; 95% confidence interval 1.62-10.1). Age >75 years, ISS >14, and sarcopenia had 1-year mortality rates of 37.1%, 30.9%, and 32.4%, respectively. In patients with all 3 factors, the mortality rate was 90%. CONCLUSION: Sarcopenia is an independent risk factor for 1-year mortality in elderly patients with acetabular fractures. This study highlights the importance of objective measures to assess frailty in elderly patients who have sustained fractures about the hip and pelvis. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Blood-loss Management in Spine Surgery.

Substantial blood loss during spine surgery can result in increased patient morbidity and mortality. Proper preoperative planning and communication with the patient, anesthesia team, and operating room staff can lessen perioperative blood loss. Advances in intraoperative antifibrinolytic agents and modified anesthesia techniques have shown promising results in safely reducing blood loss. The surgeon's attention to intraoperative hemostasis and the concurrent use of local hemostatic agents also can lessen intraoperative bleeding. Conversely, the use of intraoperative blood salvage has come into question, both for its potential inability to reduce the need for allogeneic transfusions as well as its cost-effectiveness. Allogeneic blood transfusion is associated with elevated risks, including surgical site infection. Thus, desirable transfusion thresholds should remain restrictive.