Preoperative rehabilitation optimization for spinal surgery: a narrative review of assessment, interventions, and feasibility.

PURPOSE: Postoperative physical therapy (PT) is a cornerstone of orthopedic and musculoskeletal rehabilitation, proven to provide various positive clinical benefits. However, there is a paucity of literature evaluating the utility of preoperative rehabilitation specific to spine surgery. Thus, this review article aims to provide an overview of previously published studies discussing the efficacy of preoperative rehabilitation programs and its role in spinal surgery. Special emphasis was given to preoperative frailty assessments, physical performance tests, interventional strategies, feasibility, and future directions. METHODS: We performed a literature review using PubMed, Google Scholar, EMBASE, and PubMed Central (PMC) using directed search terms. Articles that examined preoperative rehabilitation in adult spine surgery were compiled for this review. Prehabilitation programs focused on exercise, flexibility, and behavioral modifications have been shown to significantly improve pain levels and functional strength assessments in patients undergoing elective spine surgery. In addition, studies suggest that these programs may also decrease hospital stays, return to work time, and overall direct health care expenditure costs. Screening tools such as the FRAIL scale can be used to assess frailty while physical function tests like the timed-up-and go (TUGT), 5 repetition sit-to-stand test (5R-STST), and hand grip strength (HGS) can help identify patients who would most benefit from prehabilitation. CONCLUSIONS: This review illustrates that prehabilitation programs have the potential to increase quality of life, improve physical function and activity levels, and decrease pain, hospital stays, return to work time, and overall direct costs. However, there is a paucity of literature in this field that requires further study and investigation.

Preoperative Optimization for Adult Spinal Deformity Surgery: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVE: The purpose of this review is to identify modifiable risk factors in patients undergoing adult spinal deformity surgery and compile literature recommendations for the preoperative optimization of these risk factors. SUMMARY OF BACKGROUND DATA: Optimization of modifiable risk factors not only benefits the patient but also lessens resource and cost burdens on the health care system, allowing for better quality and value-based care. There is limited but applicable literature discussing preoperative optimization in adult spinal deformity surgery patients specifically. METHODS: We searched PubMed for studies that looked at one of the variables of interest (eg, osteoporosis, prehabilitation and functional status, multidisciplinary preoperative screening, infection, obesity, nutrition, smoking, diabetes, blood loss, chronic opioid use, and psychosocial factors) in adult patients with spinal deformity according to Preferred Reporting Items for Systematic Reviews and Meta-Analyse guidelines. RESULTS: Seventy studies were included in the final review and synthesis of information. Guidelines and recommendations from these studies were compared and compiled into evidence-based action items for preoperative optimization of modifiable risk factors before adult spinal deformity surgery. CONCLUSIONS: While the approach of preoperative optimization of modifiable risk factors may incur additional planning efforts and patient care time, it has the potential to significantly reduce perioperative complications and reduce morbidity and mortality during surgery, thus allowing for improved outcomes, increased quality of life, and satisfaction from this patient population. LEVEL OF EVIDENCE: 3.

Three-Dimensional Printing Applications in Pediatric Spinal Surgery: A Systematic Review.

STUDY DESIGN: Systematic Review. OBJECTIVE: 3DP technology use has become increasingly more common in the field of medicine and is notable for its growing utility in spine surgery applications. Many studies have evaluated the use of pedicle screw placement guides and spine models in adult spine patients, but there is little evidence assessing its efficacy in pediatric spine patient populations. This systematic review identifies and evaluates the current applications and surgical outcomes of 3-Dimensional Printing (3DP) technology in pediatric spinal surgery. METHODS: A search of publications was conducted using literature databases and relevant keywords in concordance with PRISMA guidelines. Inclusion criteria consisted of original studies, and studies focusing on the use of 3DP technology in pediatric spinal surgery. Studies with a focus on adult populations, non-deformity surgery, animal subjects, systematic or literature reviews, editorials, or non-English studies were excluded from further analysis. RESULTS: After application of inclusion/exclusion criteria, we identified 25 studies with 3DP applications in pediatric spinal surgery. Overall, the studies found significantly improved screw placement accuracy using 3DP pedicle screw placement guides but did not identify significant differences in operative time or blood loss. All studies that utilized 3D spine models in preoperative planning found it helpful and noted an increased screw placement accuracy rate of 89.9%. CONCLUSIONS: 3DP applications and techniques are currently used in pre-operative planning using pedicle screw drill guides and spine models to improve patient outcomes in pediatric spinal deformity patients.

Preoperative nutritional optimization for adult spinal deformity: Review.

PURPOSE: The main objective of this review article is to examine the role that nutrition has on adult spinal deformity. The information presented in this review aims to provide spine surgeons with a broad overview of screening, assessment, and interventional strategies that may be used for presurgical nutritional optimization. METHODS: A comprehensive literature review utilizing three biomedical databases was performed to generate articles of interest. Published articles related to nutrition, adult spinal deformity, spine surgery and orthopaedics were reviewed for the composition of this article. Nutrition may play a role in optimizing postoperative outcomes following adult spinal deformity surgeries, such as limiting delirium, length of stay, blood transfusion, and other medical complications. The use of screening tools, such as the PNI and CONUT score can assess preoperative nutritional status and may provide some utility in evaluating nutrition status in patients undergoing deformity surgery. Balancing both macronutrients and micronutrients, notably, carbohydrates, protein, albumin, and vitamin D can play a role in preoperative optimization. CONCLUSION: Adult spinal deformity patients are at an increased risk for malnutrition. These patients should be assessed for nutrition status to prime them for surgery, minimize complications, and maximize their outcomes. However, further studies are needed to determine how nutrition ultimately affects adult spinal deformity patients in the postoperative period and to establish specific nutritional recommendations for this unique population.

Risk factors for proximal junctional kyphosis in a multicenter study of Lenke type 5 and 6 adolescent idiopathic scoliosis patients.

PURPOSE: In Lenke type 5 and 6 curves, a major thoracolumbar or lumbar curve, the rates of PJK are reported as high as 50%. The purpose of this study was to confirm the rate of PJK, investigate possible risk factors, and evaluate surgical complications and the long-term effects of PJK on patient outcomes. METHODS: A retrospective review of multicenter data identified 192 with patients with 2 year and 94 with 5-year follow-up. Included patients had a Lenke type 5 or 6 curve and underwent a selective thoracolumbar or lumbar curve fusion. All radiographs preoperatively and postoperatively (1 year, 2 years, and 5 years) were evaluated. Demographic and radiographic data was analyzed as risk factors for PJK using a multi-variate regression. Outcomes scores and complications were compared between groups. RESULTS: 17 patients (8.9%) developed radiographic PJK; 1 at 1 year, 7 at 2 years, and another 9 at 5 years. All 17 patients had an upper instrumented vertebra (UIV) within 3 levels or less caudal of the thoracic kyphosis apex (the most horizontal vertebra on the sagittal); no patient with a UIV 4 or more levels from the thoracic apex (n = 96) developed PJK (X2 = 13.03, p < 0.001). In addition, PJA > 8° was found to significantly increase the risk of PJK (p = 0.039). SRS scores were significantly worse for PJK patients at 5 years in the self-image and function (p < 0.01). CONCLUSION: In Lenke 5/6 curves, no patient with a UIV 4 or more levels caudal to the thoracic kyphosis apex had PJK up to 5 years postoperatively. PJA greater than 8° was identified as a risk factor for PJK. Patients with radiographic PJK had worse SRS scores 5 years postoperatively.

Optimizing Preoperative Chronic Pain Management in Elective Spine Surgery Patients: A Narrative Review of Outcomes with Opioid and Adjuvant Pain Therapies.

¼ Chronic preoperative opioid use negatively affects outcomes after spine surgery, with increased complications and reoperations, longer hospital stays, decreased return-to-work rates, worse patient-reported outcomes, and a higher risk of continued opioid use postoperatively.¼ The definition of chronic opioid use is not consistent across studies, and a more specific and consistent definition will aid in stratifying patients and understanding their risk of inferior outcomes.¼ Preoperative weaning periods and maximum dose thresholds are being established, which may increase the likelihood of achieving a meaningful improvement after surgery, although higher level evidence studies are needed.¼ Spinal cord stimulators and intrathecal drug delivery devices are increasingly used to manage chronic back pain and are equivalent or perhaps even superior to opioid treatment, although few studies exist examining how patients with these devices do after subsequent spine surgery.¼ Further investigation is needed to determine whether a true mechanistic explanation exists for spine-related analgesia related to spinal cord stimulators and intrathecal drug delivery devices.

The Thoracolumbar Inflection Point in a Population of Asymptomatic Volunteers: A Multi-Ethnic Alignment Normative Study Cohort Study.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: To show population variance in the Inflection Point (IP) and its role in defining maximum Thoracic Kyphosis (TK) and Lumbar Lordosis (LL). METHODS: 468 asymptomatic adult volunteers were included in the Multi-Ethnic Normative Alignment Study (MEANS). To find parameters correlating with IP, the vertebrae and discs were numbered such that C7 was 0, T1 was 1, with T1-T2 disc being 1.5, etc. Statistical analysis was performed by a correlation matrix for IP and the 9 other selected parameters along with linear regressions. RESULTS: The overall mean IP was 12.44 approximately corresponding to T12-L1 disc with the median being 12.50, range was T8-L4. The cohort was then stratified by sex and ethnicity, but there was no significant difference in IP between groups. IP in younger subjects was 13 (L1), compared to 12.5 (T12-L1 disc) in older subjects (P < .05). IP was moderately correlated with the TK apex (r = .66). No strong correlation was found between IP and LL magnitude or apex, TK magnitude, sacral slope, or Pelvic Incidence (PI). In terms of other sagittal parameters, PI and LL demonstrated a significant positive correlation. PI and TK did not have a strong association. CONCLUSIONS: The mean IP was at the T12-L1 disc, however IP ranged from T8 to L4. Older subjects tended to have a relatively more cephalad IP. No radiographic variable was found to be a strong predictor of the IP. TK apex was found to have a moderate correlation.

High Cell Saver Autotransfusion is Associated With Perioperative Medical Complications in Adult Spinal Deformity Patients.

STUDY DESIGN: A retrospective, propensity-matched observational study. OBJECTIVE: To assess the impact of cell saver (CS) homologous transfusion on perioperative medical complications in adult patients undergoing spinal deformity surgery. SUMMARY OF BACKGROUND DATA: Despite many endorsing its use, many analyses still refute the efficacy of CS on decreasing total perioperative allogenic red blood cell transfusions, cost efficiency, and its effect on perioperative complications. METHODS: Adult patients who underwent spinal deformity surgery at a single center between 2015 and 2021 were retrospectively reviewed. Patient-specific, operative, radiographic, and 30-day complications/readmission data were collected for further analysis. Two methods were utilized to test our hypothesis: (1) absolute threshold model: two cohorts created among patients who received ≥550 mL of CS intraoperatively and those who received less; (2) adjusted ratio model: two cohorts created dependent on the ratio of CS to estimated blood loss (EBL). Propensity-score matching and various statistical tests were utilized to test the association between CS and perioperative medical complications. RESULTS: Two hundred seventy-eight patients were included in this analysis with a mean age of 61.3±15.7yrs and 67.6% being female. Using the first method, 73 patients received ≥550 mL of CS, and 205 received less. Propensity-score matching resulted in 28 pairs of patients. 39.3% of patients with ≥550 mL CS required readmission within 30 days compared with 3.57% of patients in the <550 mL cohort ( P =0.016), despite a nearly identical proportion of patients requiring intraoperative blood transfusions ( P >0.9999). Using the second method, 155 patients had CS/EBL<0.33 and 123 with CS/EBL ≥0.33. 5.16% and 21.9% among patients with CS/EBL<0.33 and CS/EBL≥0.33, respectively, were readmitted by the 30-day marker ( P <0.0001). CONCLUSIONS: Our findings indicate that greater CS volumes transfused are associated with higher rates of 30-day readmissions. Thus, surgeons should consider limiting CS volume intraoperatively to 550 mL and when greater volumes are required or preferred, ensuring that the ratio of CS:EBL remains under 0.33.

Comparison of Psychometric Properties of Patient-Reported Outcomes Measurement Information System With Traditional Outcome Metrics in Spine Surgery.

OBJECTIVE: Patient-Reported Outcomes Measurement Information System (PROMIS) was developed to address certain shortcomings of traditional, or legacy patient-reported outcome measures (PROMs). Because the use of PROMIS across orthopedic populations continues to increase, the purpose of this study was to provide a comprehensive overview of the use and validation of PROMIS in spine surgery. METHODS: PubMed and Google Scholar were searched for relevant articles reporting on the use and validation of PROMIS in spine surgery. The PROMIS formats and individual domains used by investigators were noted. Additionally, psychometric properties reported in validation studies were evaluated. RESULTS: Both individual studies and systematic reviews have demonstrated the convergent validity of PROMIS domains, reporting moderate-to-strong correlations with legacy measures in a variety of spine patient populations. Across spine surgery patient populations, PROMIS instruments are consistently efficient, demonstrating decreased question burden compared with legacy PROMs. PROMIS domains overall exhibit responsiveness comparable with legacy measures, and the normalization of PROMIS scores to a general population allows for broad coverage, resulting in acceptable floor and ceiling effects. Despite the many strengths of PROMIS, there remain some populations where PROMIS is not suited to be used in isolation. CONCLUSIONS: PROMIS is widely used as an outcome measure in spine surgery and has been validated in a range of patient populations. Although PROMIS domains cannot fully replace legacy measures in spine patients, they can be used in certain settings to provide an efficient and psychometrically sound PROM.

Predicting Bone Health Using Machine Learning in Patients undergoing Spinal Reconstruction Surgery.

STUDY DESIGN: Retrospective study of data collected prospectively. OBJECTIVE: The goal of this study is to create a predictive model of preoperative bone health status in adult patients undergoing adult spinal reconstructive (ASR) surgery using machine learning (ML). SUMMARY OF BACKGROUND DATA: Despite understanding that bone health impacts spine surgery outcomes, spine surgeons lack the tools to risk stratify patients preoperatively to determine who should undergo bone health screening. An ML approach mines patterns in data to determine the risk for poor bone health in ASR patients. MATERIALS AND METHODS: Two hundred and eleven subjects over the age of 30 with dual energy X-ray absorptiometry scans, who underwent spinal reconstructive surgery were reviewed. Data was collected by manual and automated collection from the electronic health records. The Weka software was used to develop predictive models for multiclass classification of healthy, osteopenia, and osteoporosis (OPO) bone status. Bone status was labeled according to the World Health Organization (WHO) criteria using dual energy X-ray absorptiometry T scores. The accuracy, sensitivity, specificity, and area under the receiver operating curve (AUC) were calculated. The model was evaluated on a test set of unseen data for generalizability. RESULTS: The prevalence of OPO was 23.22% and osteopenia was 52.61%. The random forest model achieved optimal performance with an average sensitivity of 0.81, specificity of 0.95, and AUC of 0.96 on the training set. The model yielded an averaged sensitivity of 0.64, specificity of 0.78, and AUC of 0.69 on the test set. The model was best at predicting OPO in patients. Numerous patient features exhibited predictive value, such as body mass index, insurance type, serum sodium level, serum creatinine level, history of bariatric surgery, and the use of medications such as selective serotonin reuptake inhibitors. CONCLUSION: Predicting bone health status in ASR patients is possible with an ML approach. Additionally, data mining using ML can find unrecognized risk factors for bone health in ASR surgery patients.

Risk of distal junctional kyphosis in scheuermann's kyphosis is decreased by selecting the LIV as two vertebrae distal to the first lordotic disc.

PURPOSE: To determine whether (1) distal junctional kyphosis (DJK) is decreased by selecting the stable sagittal vertebra (SSV), versus the vertebra below the 1st lordotic disc (1stLD), as the lowest instrumented level (LIV); (2) DJK is decreased if the LIV is two versus one vertebrae distal to the 1stLD. METHODS: A multi-institution prospective database was queried for SK patients who underwent posterior-only instrumentation and fusion with > 2 year follow-up. DJK was defined as > 10° change in the distal junctional angle postoperative from the preoperative junctional angle. Statistical analysis was performed using t test, chi-square test and logistic regression. RESULTS: Of 94 patients included, 38 (40%) developed radiographic DJK. 31 (39%) patients in whom the LIV was at or distal to the SSV developed DJK, whereas 7 (47%) in whom the LIV was proximal to the SSV developed DJK. 20 (59%) patients in whom the LIV was one vertebra below and 10 (22%) in whom the LIV was two vertebrae below the 1stLD developed DJK. Logistic regression demonstrated a significant increase in DJK development if the LIV was one vertebra below the 1stLD (OR = 3.2 (1.28-8.18)). There was not a significant relationship between DJK development and LIV position relative to the SSV. CONCLUSION: In SK surgery, LIV selection/fusion to two vertebrae below the 1stLD decreased the development of DJK. A significant relationship was not found between DJK development and location of distal fusion level in regards to the SSV, possibly due to the small number of patients who had LIV proximal to SSV.

Worse Preoperative Disability is Predictive of Improvement in Disability After Complex Adult Spinal Deformity Surgery.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVES: Few previous studies have examined the relationship between preoperative disability and patient outcomes after complex adult spinal deformity surgery. In this study, we hypothesized that patients with worse preoperative disability would be more likely achieve a clinically significant improvement in their symptoms after surgery. METHODS: Demographics, comorbidities, surgical data, and health related survey results were analyzed from a consecutive series of adults (≥18 years old) who underwent spinal deformity correction, instrumentation, and fusion. Patients included had 6 or more levels fused and their surgery performed at single institution between 2015 and 2018 with minimum 2 year follow up. RESULTS: A total of 108 patients met inclusion criteria. Bivariate analysis demonstrated the following as having a greater probability of reaching minimum clinically important difference (MCID) at 2 years postoperatively: >50th percentile Oswestry Disability Index (ODI) score (ODI >36), cardiac comorbidities, and use of pelvic fixation, pedicle subtraction osteotomy, and transforaminal lumbar interbody fusion. Conversely, baseline Scoliosis research society score (SRS) >50th percentile (SRS ≥62) and use of vertebral column resection (VCR) were significant predictors of not reaching MCID at 2 years. On logistic regression analysis, >50th percentile ODI score (ODI >36) was identified as the only independent predictor of achieving MCID. CONCLUSIONS: Patients with greater disability, independent of other preoperative or surgical factors, are more likely to have clinically significant improvement in their daily functioning after complex deformity surgery. For patients who undergo surgical intervention for severe or progressive deformity, including VCR, MCID might be an ineffective outcome measure.

A multicenter study of the 5-year trends in robot-assisted spine surgery outcomes and complications.

Background: Although a growing amount of literature that suggests robots are safe and can achieve comparable outcomes to conventional techniques, much of this literature is limited by small sample sizes and single-surgeon or single center series. Furthermore, it is unclear what the impact of robotic technology has made on operative and clinical outcomes over time. This is the first and largest multicenter study to examine the trends in outcomes and complications after robot-assisted spine surgery over a 5-year period. Methods: Adult (≥18 years old) patients who underwent spine surgery with robot-assistance between 2015 and 2019 at four unique spine centers. The robotic systems used included the Mazor Renaissance, Mazor X, and Mazor Stealth Edition. Patients with incomplete data were excluded from this study. The minimum follow-up was 90 days. Results: A total of 722 adult patients were included (117 Renaissance, 477 X, 128 Stealth). Most patient and operative factors (e.g., sex, tobacco status, total instrumented levels, and pelvic fixation,) were similar across the years. Mean ± standard deviation Charlson comorbidity index (CCI) was 1.5±1.5. The most commonly reported diagnoses included high grade spondylolisthesis (40.6%), degenerative disc disease (18.4%), and degenerative scoliosis (17.6%). Mean (standard deviation) number of instrumented levels was 3.8±3.4. From 2015 to 2019, average robot time per screw improved from 7.2 to 5.5 minutes (P=0.004, R2=0.649). Average fluoroscopy time per screw improved from 15.2 to 9.4 seconds (P=0.002). Rates of both intraoperative screw exchange for misplaced screw (2015-2016: 2.7%, 2019: 0.8%, P=0.0115, R2=0.1316) and robot abandonment (2015-2016: 7.1%, 2019: 1.1%, P=0.011, R2=0.215) improved significantly over time. The incidence of other intraoperative complications (e.g., dural tear, loss of motor/sensory function, blood transfusion) remained consistently low, but similar throughout the years. The length of stay (LOS) decreased by nearly 1 day from 2015 to 2019 (P=0.007, R2=0.779). 90-day reoperation rates did not change significantly. Conclusions: At four institutions among seven surgeons, we demonstrate robot screw accuracy, reliability, operative efficiency, and radiation exposure improved significantly from 2015 to 2019. 90-day complication rates remained low and LOS decreased significantly with time. These findings further validate continued usage of robot-assisted spine surgery and the path toward improved value-based care.

Intraoperative Anaphylaxis to the Bovine Flowable Gelatin Matrix: A Report of 2 Cases.

CASE: We present 2 cases of life-threatening intraoperative anaphylaxis to the bovine flowable gelatin matrix during pediatric spinal deformity surgery for kyphoscoliosis. Both patients had no known bovine or gelatin allergies. Anaphylaxis occurred shortly after pressurized injection into the first cannulated pedicle tract and was successfully treated with epinephrine, diphenhydramine, and methylprednisolone infusion. The allergic reaction was confirmed with tryptase levels and serum-specific immunoglobulin E for beef, pork, bovine collagen, and porcine collagen. CONCLUSION: In patients with beef, pork, or gelatin intolerance, a significant atopic history or childhood vaccine reaction, preoperative allergy consultation, and testing should be performed to prevent this life-threatening complication.

Minimum 2-Year Analysis of S2-Alar-Iliac Screw Fixation for Adult Spinal Deformity.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: Determine the rate and risk factors for S2AI screw-related pain after adult spinal deformity surgery with a minimum 2-year follow-up. METHODS: A consecutive 83 spinal deformity patients undergoing surgical treatment between August 2015 and December 2017 with minimum 2-year follow-up for S2AI screw complication and screw-related pain were included. Linear regression was performed on various risk factors and postoperative S2AI screw-related pain. Subset analysis of 53 patients was performed on preoperative and postoperative SRS and ODI scores, operative data, and radiographic data. RESULTS: The overall proportion of S2AI screw-related pain was 9.6%. An S2AI screw complication was identified radiographically in 10.8% of patients; among these, 22.2% experienced S2AI screw-related pain. 3.4% of all patients underwent S2A1 screw removal. The SRS, ODI, sagittal vertical axis (SVA), and coronal alignment scores/measurements improved following treatment in all patients. However, the mean difference for the pre and postoperative SRS function score (1.2 ± 0.5 vs 0.9 ± 0.8) and SVA (4.0 ± 4.9 cm vs 2.1 ± 4.8 cm) were higher for the pain group. CONCLUSIONS: A minimum 2-year analysis of S2AI screw fixation in adult spinal deformity patients showed that 9.6% of patients experienced S2AI screw-related pain and 3.4% of patients had S2A1 screws removed. The size and the number of S2AI screws did not predict postoperative pain, nor were radiographic findings correlated with clinical outcomes. The patient outcome scores, coronal alignment, and SVA improved for all patients, but within the pain group there was an overall larger change in the SVA and SRS function score.

Best Practice Guidelines for Assessment and Management of Osteoporosis in Adult Patients Undergoing Elective Spinal Reconstruction.

STUDY DESIGN: Expert consensus study. OBJECTIVE: This expert panel was created to establish best practice guidelines to identify and treat patients with poor bone health prior to elective spinal reconstruction. SUMMARY OF BACKGROUND DATA: Currently, no guidelines exist for the management of osteoporosis and osteopenia in patients undergoing spinal reconstructive surgery. Untreated osteoporosis in spine reconstruction surgery is associated with higher complications and worse outcomes. METHODS: A multidisciplinary panel with 18 experts was assembled including orthopedic and neurological surgeons, endocrinologists, and rheumatologists. Surveys and discussions regarding the current literature were held according to Delphi method until a final set of guidelines was created with over 70% consensus. RESULTS: Panelists agreed that bone health should be considered in every patient prior to elective spinal reconstruction. All patients above 65 and those under 65 with particular risk factors (chronic glucocorticoid use, high fracture risk or previous fracture, limited mobility, and eight other key factors) should have a formal bone health evaluation prior to undergoing surgery. DXA scans of the hip are preferable due to their wide availability. Opportunistic CT Hounsfield Units of the vertebrae can be useful in identifying poor bone health. In the absence of contraindications, anabolic agents are considered first line therapy due to their bone building properties as compared with antiresorptive medications. Medications should be administered preoperatively for at least 2 months and postoperatively for minimum 8 months. CONCLUSION: Based on the consensus of a multidisciplinary panel of experts, we propose best practice guidelines for assessment and treatment of poor bone health prior to elective spinal reconstructive surgery. Patients above age 65 and those with particular risk factors under 65 should undergo formal bone health evaluation. We also established guidelines on perioperative optimization, utility of various diagnostic modalities, and the optimal medical management of bone health in this population.Level of Evidence: 5.

A Systematic Review of the Orthopaedic Literature on Truncal and Lower Extremity Injuries in Major League Baseball Players.

BACKGROUND: Orthopaedic injuries in Major League Baseball (MLB) players can have a tremendous impact on player health, longevity, salaries, and time lost from play. PURPOSE: To summarize all data published between January 1980 and August 2019 on truncal and lower extremity orthopaedic injuries sustained by MLB players. METHODS: A literature review of studies examining injuries in MLB was performed using the PubMed and Embase databases. Included studies focused on truncal and lower extremity injuries in professional baseball players. Studies pertaining to nonorthopaedic injuries, and case reports, were excluded. RESULTS: A total of 41 articles met the inclusion criteria and were selected for the final analysis. Articles were divided based on anatomic region of injury: hip and pelvis (16%), thigh (15%), truncal (14%), knee (13%), and ankle (11%). Most studies (83.7%) were level 3 evidence. Most studies obtained data using publicly available internet resources (29.8%) compared with the MLB Health and Injury Tracking System (22.1%). CONCLUSION: This review provides physicians with a single source of the most current literature regarding truncal and lower extremity orthopaedic injuries in MLB players. Most research was published on hip and pelvic, truncal, and thigh injuries and consisted of level III evidence.

The Telehealth Spine Physical Examination: A Practical Approach Learned During the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic has led to a surge in the use of telehealth visits across the country to minimize in-person visits and to limit the spread of COVID-19. To date, no standards or outlines for telehealth spine examinations have been detailed and many surgeons simply defer the physical examination when performing telehealth visits. Nevertheless, just as physical examination of the spine is an integral part of live clinical encounters, appropriately modified physical examinations should also be part of virtual visits. METHODS: In this study we provide our methodology for guiding providers and patients in efficiently performing telehealth spine examinations. RESULTS: The study details steps for efficiently performing a physical examination in the telehealth setting. Our written suggestions are supplemented with photographs and video recordings to help streamline the virtual examination. CONCLUSIONS: An effective and efficient spine physical examination can be performed during telehealth visits. Future directions include verifying the findings from our virtual physical examination with in-person examinations.

Oral Administration of a Chemically Modified Curcumin, TRB-N0224, Reduced Inflammatory Cytokines and Cartilage Erosion in a Rabbit ACL Transection Injury Model.

OBJECTIVE: To evaluate the effects of TRB-N0224, a chemically modified curcumin (CMC) with zinc binding properties and improved pharmacokinetics, in a rabbit anterior cruciate ligament (ACL) transection injury-induced model of osteoarthritis (OA). DESIGN: Thirty-eight skeletally mature New Zealand white rabbits were studied in 4 groups: a sham with arthrotomy (n = 6), control with ACL transection (n = 6), and 2 treatment groups with ACL transection and administration of TRB-N0224 at low (25 mg/kg/day) (n = 13) and high (50 mg/kg/day) (n = 13) doses. After euthanization at 12 weeks, outcomes were measured by post-necropsy gross morphology, biomechanics, and cartilage and synovium histology. Rabbit blood ELISA quantified cytokine and matrix metalloproteinase (MMP) concentrations at 0, 4, 8, and 12 weeks. RESULTS: Both treatment doses had fewer distal femoral condyle erosive defects than the control; the low dose demonstrated a mean 78% decrease (P < 0.01). Histologically, the low- and high-dose treatment groups had fewer cartilage pathologic changes and less severe synovitis than the control. CMC alone did not have a major effect on the biomechanics of healthy cartilage or cartilage in the ACL transection model, as demonstrated in 5 of the 6 measured properties/regions (P < 0.05). ELISA results suggested that the key mediators of OA, (interleukin) IL-1ß, IL-6, TNFα (tumor necrosis factor-α), MMP-9, and MMP-13, had decreased concentrations with TRB-N0224 treatment at different time points between weeks 4 to 12 (P < 0.05). CONCLUSIONS: In the pathogenesis of OA, an imbalance exists between catabolic and anabolic mediators. These results suggest the potential of TRB-N0224 to modulate MMP and cytokine levels, slowing the macroscopic and histopathological progression of OA.