The Effects of Marijuana Use on Lumbar Spinal Fusion.

MINI: This study compared clinical and patient-reported outcomes following transforaminal lumbar interbody fusion between patients who use or do not use marijuana. We found that patients who use marijuana are younger, but do not demonstrate any differences in preoperative or postoperative Oswestry disability index scores or rates of fusion. STUDY DESIGN: A retrospective cohort study. OBJECTIVE: The purpose of this study was to evaluate marijuana usage and its effect on outcomes following transforaminal lumbar interbody fusion (TLIF). SUMMARY OF BACKGROUND DATA: As marijuana becomes legalized throughout the United States, its medicinal and recreational usage is becoming more mainstream. Clinicians currently have little guidance regarding both short-term and long-term effects of marijuana usage on surgical interventions. While the rate of lumbar spinal fusion in the United States continues to grow, the effect of marijuana usage on fusion remains uncertain. METHODS: One hundred two patients who underwent TLIF performed by the same surgeon were followed for 12 months. Patients were self-reported for marijuana usage (n = 36). Patient reported outcome measures included preoperative Oswestry disability index (ODI), 6-month ODI, and 12-month ODI, as well as length of stay (LOS), complications, return to operating room (OR), revision surgery, and confirmed fusion. Continuous variables were compared using the independent two-sample t test or analysis of variance (ANOVA), whereas categorical variables were analyzed using the chi-square or Fischer exact tests. Adjusted analysis was performed using a multivariate logistic regression model. RESULTS: Marijuana usage was associated with a younger population (P < 0.001), but showed no difference regarding sex or body mass index compared with the non-usage group. There was no statistically significant difference in complications, return to OR, or revision surgery between groups. When controlling for factors such as age and preoperative ODI, multivariate analysis demonstrated that marijuana usage did not limit postoperative ODI reduction. The marijuana usage group demonstrated shorter LOS (2.42 vs. 3.00 d, P = 0.020). Fusion rates at 12 months were similar between groups (96% vs. 92.3%, P = 0.678). ODI was similar between groups at all time points. CONCLUSION: Perioperative outcomes were similar in patients who underwent TLIF regardless of marijuana usage. LEVEL OF EVIDENCE: 3.

A retrospective cohort study. The purpose of this study was to evaluate marijuana usage and its effect on outcomes following transforaminal lumbar interbody fusion (TLIF). As marijuana becomes legalized throughout the United States, its medicinal and recreational usage is becoming more mainstream. Clinicians currently have little guidance regarding both short-term and long-term effects of marijuana usage on surgical interventions. While the rate of lumbar spinal fusion in the United States continues to grow, the effect of marijuana usage on fusion remains uncertain. One hundred two patients who underwent TLIF performed by the same surgeon were followed for 12 months. Patients were self-reported for marijuana usage (n = 36). Patient reported outcome measures included preoperative Oswestry disability index (ODI), 6-month ODI, and 12-month ODI, as well as length of stay (LOS), complications, return to operating room (OR), revision surgery, and confirmed fusion. Continuous variables were compared using the independent two-sample t test or analysis of variance (ANOVA), whereas categorical variables were analyzed using the chi-square or Fischer exact tests. Adjusted analysis was performed using a multivariate logistic regression model. Marijuana usage was associated with a younger population (P < 0.001), but showed no difference regarding sex or body mass index compared with the non-usage group. There was no statistically significant difference in complications, return to OR, or revision surgery between groups. When controlling for factors such as age and preoperative ODI, multivariate analysis demonstrated that marijuana usage did not limit postoperative ODI reduction. The marijuana usage group demonstrated shorter LOS (2.42 vs. 3.00 d, P = 0.020). Fusion rates at 12 months were similar between groups (96% vs. 92.3%, P = 0.678). ODI was similar between groups at all time points. Perioperative outcomes were similar in patients who underwent TLIF regardless of marijuana usage. Level of Evidence: 3.

Single-center, consecutive series study of the use of a novel platelet-rich fibrin matrix (PRFM) and beta-tricalcium phosphate in posterolateral lumbar fusion.

PURPOSE: To evaluate the radiographic and clinical outcomes of the combination of platelet-rich fibrin matrix (PRFM) with beta-tricalcium phosphate (ß-TCP) and bone marrow aspirate (BMA) as a graft alternative in posterolateral lumbar fusion procedures. METHODS: Researchers evaluated 50 consecutive patients undergoing one-level to three-level posterolateral lumbar fusion procedures, resulting in a total of 66 operated levels. The primary outcome was evidence of radiographic fusion at 1-year follow-up, assessed by three independent evaluators using the Lenke scoring system. Secondary outcomes included back and leg VAS scores, incidence of reoperations and complications, return-to-work status, and opioid use. RESULTS: At 1-year follow-up, radiographic fusion was observed in 92.4% (61/66) of operated levels. There was significant improvement in VAS scores for both back and leg pain (p < 0.05). Compared to baseline figures, the number of patients using opioid analgesics at 12-months decreased by 38%. The majority (31/50) of patients were retired, yet 68% of employed patients (n = 19) were able to return to work. No surgical site infections were noted, and no revision surgery at the operated level was required. CONCLUSIONS: This is the first report to analyze the combination of PRFM with ß-TCP and BMA for PLF procedures. Our results indicate a rate of fusion similar to those reported using iliac crest bone graft (ICBG), while avoiding donor site morbidity related to ICBG harvesting such as hematoma, pain, and infection. These slides can be retrieved under Electronic Supplementary Material.

Etiology and Surgical Management of Cervical Spinal Epidural Abscess (SEA):: A Systematic Review.

STUDY DESIGN: Systematic analysis and review. OBJECTIVE: Evaluation of the presentation, etiology, management strategies (including both surgical and nonsurgical options), and neurological functional outcomes in patients with cervical spinal epidural abscess (SEA). METHODS: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria were used to create a framework based on which articles pertaining to cervical SEA were chosen for review following a search of the Ovid and PubMed databases using the search terms "epidural abscess" and "cervical." Included studies needed to have at least 4 patients aged 18 years or older, and to have been published within the past 20 years. RESULTS: Database searches yielded 521 potential articles in PubMed and 974 potential articles in Ovid. After review, 11 studies were ultimately identified for inclusion in this systematic review. Surgery appears to be a well-tolerated management strategy with limited complications for patients with cervical SEA. However, the quantity of data comparing medical and surgical treatment of cervical SEA is limited and the bulk of the data is derived from low quality studies. CONCLUSION: Data reporting was heterogeneous among studies making it difficult to draw discrete conclusions. Early surgical intervention may be appropriate in selected patients with cervical epidural abscess, but it is not clear what distinguishes these patients from those who are successfully managed nonoperatively.

The Effect of Aging on Cervical Parameters in a Normative North American Population.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To investigate age-based changes in cervical alignment parameters in an asymptomatic population. METHODS: Retrospective review of a prospective study of 118 asymptomatic subjects who underwent biplanar imaging with 3-dimensional capabilities. Demographic and health-related quality of life data was collected prior to imaging. Patients were stratified into 5 age groups: <35 years, 35-44 years, 45-54 years, 55-64 years, and ≥65 years. Radiographic measurements of the cervical spine and spinopelvic parameters were compared between age groups. The normal distribution of parameters was assessed followed by analysis of variance for comparison of variance between age groups. RESULTS: C2-C7 lordosis, C0-C7 lordosis, and T1 slope demonstrated significant increases with age. C0-C7 lordosis was significantly less in subjects <35 years compared with ≥55 years. Significant differences in T1 slope were identified in patients <35 versus ≥65, 35-44 versus ≥65, and 45-54 versus ≥65 years. T1 slope demonstrated a positive correlation with age. Horizontal gaze parameters did not change linearly with age and mean averages of all age groups were within 10° of one another. Cervical kyphosis was present in approximately half of subjects who were <55 compared with approximately 10% of subjects ≥55 years. Differences in pelvic tilt, pelvic incidence-lumbar lordosis, and C7-S1 sagittal vertical axis were identified with age. CONCLUSIONS: C0-C7 lordosis, C2-C7 lordosis, and T1 slope demonstrate age-based changes while other cervical and horizontal gaze parameters remain relatively constant with age.

Variability in Assessing Spinopelvic Parameters With Lumbosacral Transitional Vertebrae: Inter- and Intraobserver Reliability Among Spine Surgeons.

STUDY DESIGN: Prospectively collected survey study OBJECTIVE.: The aim of this study was to determine the consistency with which spinopelvic parameters (SPP) are determined in patients with lumbosacral transitional vertebrae (LSTV). SUMMARY OF BACKGROUND DATA: The incidence of LSTV in the general population is as high as 35.6%. The often fixed nature of LSTV relative to the pelvis, but lumbar-type appearance, may lead to differential use of the S1 endplate when performing SPP assessment. This could have significant impact on SPP derived from these landmarks, resulting in considerable variation in surgical planning and decision-making. METHODS: Twenty patients demonstrating LSTV on standing lateral 36-inch spinal radiographs were randomly arranged and independently analyzed by 16 experienced spine surgeons using the same computer software. Pelvic incidence (PI), pelvic tilt (PT), lumbar lordosis (LL), and T1 pelvic angle (TPA) were captured. Two weeks after the first assessment, surgeons repeated the measurements after image sequence re-randomization. Intraclass correlation coefficient (ICC) was calculated to evaluate interobserver reliability (IOR) for each SPP. Intraobserver reliability (IAOR) was assessed through an average Pearson correlation coefficient for each parameter for each surgeon. RESULTS: Sixteen surgeons completed initial measurements. IOR was poor for TPA (0.35, 95% confidence interval [CI] 0.20, 0.58) and PI (0.42, 95% CI 0.26, 0.65) and fair for LL (0.67, 95% CI 0.51, 0.82), and PT (0.63, 95% CI 0.47, 0.81). Fourteen surgeons completed phase-2 measurements to assess IAOR. Average parameter PPC showed excellent IAOR (LL 0.86, TPA 0.77, PI 0.78, PT 0.86). Kappa coefficient showed fair agreement for raters choosing the same endplate for measurement (Phase 1: 0.38, Phase 2: 0.32). By patient, the percentage of raters that chose the S1 endplate for measurement varied from 6.3% to 85.7%. CONCLUSION: Significant variability exists when surgeons measure SPP in patients with LSTV. These parameters are critical in determining the goals of surgical reconstruction and such variability may have considerable implications for radiographic goals and outcomes of surgical reconstruction. LEVEL OF EVIDENCE: 4.

Bisphosphonate's and Intermittent Parathyroid Hormone's Effect on Human Spinal Fusion: A Systematic Review of the Literature.

There has been a conscious effort to address osteoporosis in the aging population. As bisphosphonate and intermittent parathyroid hormone (PTH) therapy become more widely prescribed to treat osteoporosis, it is important to understand their effects on other physiologic processes, particularly the impact on spinal fusion. Despite early animal model studies and more recent clinical studies, the impact of these medications on spinal fusion is not fully understood. Previous animal studies suggest that bisphosphonate therapy resulted in inhibition of fusion mass with impeded maturity and an unknown effect on biomechanical strength. Prior animal studies demonstrate an improved fusion rate and fusion mass microstructure with the use of intermittent PTH. The purpose of this study was to determine if bisphosphonates and intermittent PTH treatment have impact on human spinal fusion. A systematic review of the literature published between 1980 and 2015 was conducted using major electronic databases. Studies reporting outcomes of human subjects undergoing 1, 2, or 3-level spinal fusion while receiving bisphosphonates and/or intermittent PTH treatment were included. The results of relevant human studies were analyzed for consensus on the effects of these medications in regards to spinal fusion. There were nine human studies evaluating the impact of these medications on spinal fusion. Improved fusion rates were noted in patients receiving bisphosphonates compared to control groups, and greater fusion rates in patients receiving PTH compared to control groups. Prior studies involving animal models found an improved fusion rate and fusion mass microstructure with the use of intermittent PTH. No significant complications were demonstrated in any study included in the analysis. Bisphosphonate use in humans may not be a deterrent to spinal fusion. Intermittent parathyroid use has shown early promise to increase fusion mass in both animal and human studies but further studies are needed to support routine use.

Distal Fusion Level Selection in Scheuermann's Kyphosis: A Comparison of Lordotic Disc Segment Versus the Sagittal Stable Vertebrae.

STUDY DESIGN: Retrospective study. OBJECTIVE: To compare 2 methods of selecting the lowest instrumented vertebra (LIV) on the rates of revision surgery for distal junctional kyphosis (DJK) following treatment for Scheuermann's kyphosis (SK). METHODS: A retrospective review of patients who have undergone surgical treatment for SK was performed. Forty-four patients were divided into 2 groups based on intervention: Group 1 (n = 26) included patients who had an LIV distal to or at the sagittal stable vertebrae (SSV), and Group 2 (n = 18) included patients who had an LIV proximal to the SSV. For each group, demographic, radiographic, and revision surgery data was analyzed. RESULTS: The average follow-up was 3.1 years. There were no differences among demographic variables between the groups. Preoperative and postoperative thoracic kyphosis, lumbar lordosis, and sagittal balance were not different between groups. Postoperatively, Group 1 demonstrated a significantly greater average lordotic disc angle below the LIV compared with Group 2 (Group 1, -6.2 ± 4.3° vs Group 2, -2.9 ± 5.8°; P = .02). In a subgroup analysis, extending fusions to the sagittal stable vertebra rather than the first lordotic disc resulted in fewer distal LIV complications necessitating revision surgery compared with fusing short of the SSV (5% vs 36.3%, P = .04). CONCLUSION: The SSV method may reduce complications secondary to distal junctional failure, but at the expense of incorporating additional motion segments in a typically young population.

Serial Casting for Infantile Idiopathic Scoliosis: Radiographic Outcomes and Factors Associated With Response to Treatment.

BACKGROUND: Serial casting for early-onset scoliosis has been shown to improve curve deformity. Our goal was to define clinical and radiographic features that determine response to treatment. METHODS: We retrospectively reviewed patients with idiopathic infantile scoliosis with a minimum of 2-year follow-up. Inclusion criteria were: progressive idiopathic infantile scoliosis and initial casting before 6 years of age. Two groups were analyzed and compared: group 1 (≥10-degree improvement in Cobb angle from baseline) and group 2 (no improvement). RESULTS: Twenty-one patients with an average Cobb angle of 48 degrees (range, 24 to 72 degrees) underwent initial casting at an average age of 2.1 years (range, 0.7 to 5.4 y). Average follow-up was 3.5 years (range, 2 to 6.9 y). Sex, age at initial casting, magnitude of spinal deformity, and curve flexibility (defined as change in Cobb angle from pretreatment to first in-cast radiograph) were not significantly different between groups (P>0.05). Group 1 had a significantly higher body mass index (BMI) than group 2 at the onset of treatment (17.6 vs. 14.8, P<0.05). Univariate analysis of demographic, radiographic, and treatment factors revealed that only BMI was predictive of Cobb improvement (P=0.04; odds ratio=2.38). Group 1 (n=15) had a significantly lower Cobb angle (21 vs. 56 degrees) and rib vertebral angle difference (13 vs. 25 degrees) compared with group 2 at latest follow-up (P<0.05). A significantly larger proportion of children who were casted at less than 1.8 years of age had a Cobb angle <20 degrees at latest follow-up (P=0.03). Group 2 maintained stable clinical and radiograph parameters from pretreatment to most recent follow-up. CONCLUSIONS: To maintain a homogeneous cohort, we excluded patients with syndromes and developmental delays. We believe that analyzing a homogeneous group provides more meaningful results than if we studied a heterogeneous sample. BMI was significantly associated with outcome such that for each unit increase in BMI, there is a 2.38× increase in the chance of improvement. Curve flexibility was similar between groups, which suggest that the amount of correction obtained at initial casting does not confirm treatment success. Key aspects of treatment that may determine success include age of less than 1.8 years at initiation of casting and derotation of the spine to correct rib vertebral angle difference of <20 degrees. LEVEL OF EVIDENCE: Level IV-Therapeutic.

Neurological complications in adult spinal deformity surgery.

The number of surgeries performed for adult spinal deformity (ASD) has been increasing due to an aging population, longer life expectancy, and studies supporting an improvement in health-related quality of life scores after operative intervention. However, medical and surgical complication rates remain high, and neurological complications such as spinal cord injury and motor deficits can be especially debilitating to patients. Several independent factors potentially influence the likelihood of neurological complications including surgical approach (anterior, lateral, or posterior), use of osteotomies, thoracic hyperkyphosis, spinal region, patient characteristics, and revision surgery status. The majority of ASD surgeries are performed by a posterior approach to the thoracic and/or lumbar spine, but anterior and lateral approaches are commonly performed and are associated with unique neural complications such as femoral nerve palsy and lumbar plexus injuries. Spinal morphology, such as that of hyperkyphosis, has been reported to be a risk factor for complications in addition to three-column osteotomies, which are often utilized to correct large deformities. Additionally, revision surgeries are common in ASD and these patients are at an increased risk of procedure-related complications and nervous system injury. Patient selection, surgical technique, and use of intraoperative neuromonitoring may reduce the incidence of complications and optimize outcomes.

Biomechanics of Degenerative Spinal Disorders.

The spine has several important functions including load transmission, permission of limited motion, and protection of the spinal cord. The vertebrae form functional spinal units, which represent the smallest segment that has characteristics of the entire spinal column. Discs and paired facet joints within each functional unit form a three-joint complex between which loads are transmitted. Surrounding the spinal motion segment are ligaments, composed of elastin and collagen, and joint capsules which restrict motion to within normal limits. Ligaments have variable strengths and act via different lever arm lengths to contribute to spinal stability. As a consequence of the longer moment arm from the spinous process to the instantaneous axis of rotation, inherently weaker ligaments (interspinous and supraspinous) are able to provide resistance to excessive flexion. Degenerative processes of the spine are a normal result of aging and occur on a spectrum. During the second decade of life, the intervertebral disc demonstrates histologic evidence of nucleus pulposus degradation caused by reduced end plate blood supply. As disc height decreases, the functional unit is capable of an increased range of axial rotation which subjects the posterior facet capsules to greater mechanical loads. A concurrent change in load transmission across the end plates and translation of the instantaneous axis of rotation further increase the degenerative processes at adjacent structures. The behavior of the functional unit is impacted by these processes and is reflected by changes in the stress-strain relationship. Back pain and other clinical symptoms may occur as a result of the biomechanical alterations of degeneration.

Acute Tetraplegia after Posterior Cervical Laminectomy for Chronic Myelopathy.

Spinal cord injury (SCI) during revision surgery for persistent multilevel cervical myelopathy (MCM) after an initial anterior procedure is rare. However, the pathophysiology of MCM, even prior to surgery, is a risk-factor for neurological deterioration due to the development of a "sick cord", which reflects pathological changes in the spinal cord that lower the threshold for injury. We report a case of persistent MCM despite a three-level ACDF and corpectomy who developed an incomplete C6 tetraplegia during revision cervical laminectomy and posterior instrumentation. Intraoperative neuromonitoring signal-changes occurred in the absence of mechanical trauma. Postoperative MRI of the cervical spine demonstrated increased T2 hyperintensity and cord expansion at C3 and C4 compared to the pre-laminectomy MRI. The patient has not made improvements in her neurological status at 13 months postoperatively. The pathophysiology of MCM is discussed in addition to perioperative imaging, neuromonitoring, and use of steroids.

Intraoperative Fluoroscopy Improves Component Position During Anterior Hip Arthroplasty.

The goal of this retrospective review was to determine whether fluoroscopic guidance improves acetabular cup abduction and anteversion alignment during anterior total hip arthroplasty. The authors retrospectively reviewed 199 patients (fluoroscopy group, 98; nonfluoroscopy group, 101) who underwent anterior total hip arthroplasty at a single center with and without C-arm fluoroscopy guidance. Included in the study were patients of any age who underwent primary anterior approach total hip arthroplasty performed by a single surgeon, with 6-month postoperative anteroposterior pelvis radiographs. Acetabular cup abduction and anteversion angles were measured and compared between groups. Mean acetabular cup abduction and anteversion angles were 43.4° (range, 26.0°-57.4°) and 23.1° (range, 17°-28°), respectively, in the fluoroscopy group. Mean abduction and anteversion angles were 45.9° (range, 29.7°-61.3°) and 23.1° (range, 17°-28°), respectively, after anterior total hip arthroplasty without the use of C-arm guidance (nonfluoroscopy group). The use of fluoroscopy was associated with a statistically significant difference in cup abduction (P=.002) but no statistically significant difference in anteversion angles. In the fluoroscopy group, 80% of implants were within the combined safe zone compared with 63% in the nonfluoroscopy group. A significantly higher percentage of both acetabular cup abduction angles and combined anteversion and abduction angles were in the safe zone in the fluoroscopy group. Fluoroscopy is not required for proper anteversion placement of acetabular components, but it may increase ideal safe zone placement of components.

Profunda Femoris Pseudoaneurysm following Total Hip Arthroplasty Revision.

Vascular injuries following total hip arthroplasty (THA) are very rare, with pseudoaneurysm being a small subset. We report a case of profunda femoris artery (PFA) pseudoaneurysm in a 61-year-old male following a posterior approach revision left THA. Presentation involved continued blood transfusion requirements several weeks postoperatively. Diagnosis of the pseduoaneurysm was made by contrast CT of the lower extremity, with confirmation via IR angiography. Successful embolization was achieved with selective coiling and Gelfoam. Presenting complaints of such complications are often vague and therefore lead to delayed diagnosis. Causes of such complications are not completely understood, particularly with PFA injuries in THA. Possible mechanisms are discussed in this paper. Vascular complications following THA can be difficult to diagnose. High suspicion in the setting of continued postoperative pain or bleeding may allow prompt diagnosis and avoidance of serious limb-threatening complications.

Percutaneous Sacroiliac Screw Fixation of the Posterior Pelvic Ring.

Percutaneous sacroiliac (SI) screw fixation is indicated for unstable posterior pelvic ring injuries, sacral fractures, and SI joint dislocations. This article provides a review of indications and contraindications, preoperative planning, imaging techniques and relevant anatomy, surgical technique, complications and their management, and outcomes after SI screw insertion.

Gunshot injuries of the spine.

BACKGROUND CONTEXT: Spinal gunshot injuries (spinal GSIs) are a major cause of morbidity and mortality in both military and civilian populations. These injuries are likely to be encountered by spine care professionals in many treatment settings. A paucity of resources is available to summarize current knowledge of spinal GSI evaluation and management. PURPOSE: The aim was to summarize the ballistics, epidemiology, evaluation, treatment, and outcomes of spinal GSI among civilian and military populations. STUDY DESIGN: This was a review of the current literature reporting spinal GSI management. METHODS: MEDLINE (PubMed) was queried for recent studies and case reports of spinal GSI evaluation and management. RESULTS: Spinal GSI now comprise the third most common cause of spinal injury. Firearms that produce spinal GSI can be divided into categories of high- and low-energy depending on the initial velocity of the projectile. Neural and mechanical spinal damage varies with these types and results from several factors including direct impact, concussion waves, tissue cavitation, and thermal energy. Management of spinal GSI also depends on several factors including neurologic function and change over time, spinal stability, missile tract through the body, and concomitant injury. Surgical treatment is typically indicated for progressive neurologic changes, spinal instability, persistent cerebrospinal fluid leak, and infection. Surgical treatment for GSI affecting T12 and caudal often has a better outcome than for those cranial to T12. Surgical exploration and removal of missile fragments in the spinal canal are typically indicated for incomplete or worsening neurologic injury. CONCLUSIONS: Treatment of spinal GSI requires a multidisciplinary approach with the goal of maintaining or restoring spinal stability and neurologic function and minimizing complications. Concomitant injuries and complications after spinal GSI can present immediate and ongoing challenges to the medical, surgical and rehabilitative care of the patient.

Minimally Invasive Lateral Interbody Fusion in the Treatment of Scoliosis Associated with Myelomeningocele.

INTRODUCTION: Surgical correction of spinal deformity in myelomeningocele is associated with high rates of pseudarthrosis and implant failure. The anterior fusion is traditionally a wide exposure from the thorax to the sacrum. We report minimally invasive lateral interbody fusion (MILIF) to address the issue of fusion between vertebrae with marginal posterior elements while minimizing the morbidity of an open approach. MATERIALS AND METHODS: We performed a single-center, retrospective review of patients with myelomeningocele and severe scoliosis who underwent posterior spinal fusion (PSF) and staged MILIF for anterior fusion of the thoracolumbar/lumbar spine. We identified four patients with high risk of curve progression who met the following inclusion criteria: diagnosis of myelomeningocele, severe scoliosis (Cobb angle>70°), PSF using greater than 80% pedicle screws, age greater than 10 years at time of surgery, and a minimum follow-up of two years. Radiographic, clinical, and complication data were reviewed. RESULTS: All four patients achieved fusion (100%). The average age at index surgery was 12.8 years (range, 11-16) and follow-up was 3.2 years (range, 2-4.9). The average preoperative coronal Cobb angle measured 111° (range, 74-140°). The average postoperative Cobb angle at follow-up measured 37° (range, 23-42°). The MILIF procedure was performed an average of six months after the index procedure. After anterior fusion, all patients spent one day in the pediatric ICU and an average of 5.5 days in the hospital (range, 4-7). One patient (25%) developed a postoperative wound infection after PSF which required irrigation and debridement in the operating room. CONCLUSION: MILIF as an adjunct to posterior spinal fusion for severe scoliosis associated with myelomeningocele may provide acceptable fusion rates, curve correction, maintenance of correction at mid-term follow-up, and be associated with less morbidity than the traditional anterior approach.

Nerve and tendon injury with percutaneous fibular pinning: a cadaveric study.

OBJECTIVE: The purposes of this study were to measure the average distance from a percutaneous pin in each quadrant of the distal fibula to the sural nerve and nearest peroneal tendon, and define the safe zone for percutaneous pin placement as would be used during surgery. METHOD: Ten fresh-frozen cadavers underwent percutaneous pin fixation into four quadrants of the distal fibula. The sural nerve and peroneal tendon were identified as they coursed around the lateral ankle. Distances from the K-wire in each quadrant to the anatomic structure of interest were measured. RESULTS: Average distances (mm) from the K-wire to the sural nerve in the anterolateral, anteromedial, posterolateral, and posteromedial quadrants were 19.1±8.9 (range, 5.1-35.5), 12.8±8.2 (range, 0.3-27.8), 12.6±6.8 (range, 3.0-27.8), and 5.9±5.5 (range, 0.1-19.9), respectively. Average distances from the K-wire to the nearest peroneal tendon in the anterolateral, anteromedial, posterolateral, and posteromedial quadrants were 15.7±4.4 (range, 9.5-23.1), 11.9±5.2 (range, 3.2-21.7), 6.3±3.9 (range, 0.1-14.4), and 1.0±1.6 (range, 0-5.6), respectively. CONCLUSIONS: Percutaneous pinning of distal fibula fractures is a successful treatment option with minimal complications. Our anatomical study found the safe zone of percutaneous pin placement to be in the anterolateral quadrant. The sural nerve can be as close as 5.1mm and the peroneal tendons as near as 15.7mm. In contrast, the posteromedial quadrant was associated with the greatest risk of injury to both the sural nerve and peroneal tendons.

Povidone-iodine soaks for hand abscesses: a prospective randomized trial.

PURPOSE: To determine the effect of povidone-iodine soaks on outcomes of hand infections after operative drainage. METHODS: We performed a single-center, prospective, randomized trial to evaluate 100 consecutive hand infections. Forty-nine patients received povidone-iodine soaks 3 times daily, and 51 patients received only daily dressing changes. Outcome measures were the number of operations, readmissions, reoperations for wound complications, and days spent in the hospital. RESULTS: Patients treated with povidone soaks averaged 1.6 operations, and patients treated with daily dressing changes averaged 1.4 operations, a statistically insignificant difference. The mean number of operations was also not different between groups for the dorsal hand or dorsal finger abscess subcategories. No significant differences were found in length of stay, number of readmissions, or number of reoperations for wound complications. CONCLUSIONS: Povidone-iodine soaks are not helpful in the postoperative management of hand infections TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Does Amicar affect blood loss in patients with adolescent idiopathic scoliosis treated with pedicle screws and Ponte osteotomies?

Amicar may affect estimated blood loss (EBL) and blood transfusion in patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion (PSF) with pedicle screws and Ponte osteotomies. We performed a retrospective analysis of a prospectively collected, single-center database of 33 patients with main thoracic AIS treated with greater than 80% pedicle screws. Patients were divided into two groups based on whether they received Amicar (Yes), or did not receive any antifibrinolytics and Ponte osteotomies (No). Demographic, radiographic, and intraoperative data were compared between the two groups. Seventeen patients were treated with Amicar (Yes) (10 of whom had Ponte osteotomies) and 16 patients had neither antifibrinolytics nor Ponte osteotomies (No). The two groups had similar preoperative main Cobb angles, major curve flexibility, and gender. Despite longer operating times and a majority of patients receiving Ponte osteotomies, the Amicar group had a significantly lower EBL and homologous blood transfusion rate. Autologous transfusion volume was less in the Amicar group and trended toward significance. There were no differences in mean arterial pressure during surgery. There were no complications in either group. Amicar reduces EBL and homologous transfusion requirements in patients with main thoracic AIS undergoing PSF with pedicle screws and Ponte osteotomies.

Upregulation of CD59: potential mechanism of accommodation in a large animal model.

BACKGROUND: Survival of ABO-mismatched kidneys with stable renal function despite the persistence of anti-ABO antibodies is called accommodation. The mechanism of accommodation is unclear, but may involve complement regulatory proteins such as CD59. The development of alpha-1,3-galactosyltransferase knock-out (GalT-KO) swine that produce anti-Gal antibodies provides a large animal model capable of determining the role of complement regulatory proteins in accommodation. METHODS: ELISA and antibody fluorescence-activated cell sorting were used to examine the rate of anti-Gal antibody expression as a function of age. Major histocompatibility complex-matched kidneys were transplanted from Gal-positive MGH miniature swine to MGH GalT-KO swine with systemic immunosuppression. One recipient underwent adsorbtion of anti-Gal antibodies before transplantation. Graft survival, antibody, and complement deposition patterns and CD59 expression were determined. RESULTS: Three animals rejected Gal-positive kidneys by humoral mechanisms. One animal with low titers of anti-Gal antibody displayed spontaneous accommodation and the animal that was treated with antibody adsorbtion also displayed accommodation. Rejected grafts had deposition of IgM, IgG, C3, and C5b-9 with low expression of CD59, whereas accommodated grafts had low deposition of C5b-9 and high expression of CD59. Retransplantation of one accommodated graft to a naïve GalT-KO animal confirmed that changes in the graft were responsible for the lack of C5b-9 deposition. CONCLUSION: GalT-KO miniature swine produce anti-Gal antibodies and titers increase with age. These anti-Gal antibodies can cause rejection of major histocompatibility complex-matched kidneys unless accommodation occurs. CD59 up-regulation seems to be involved in the mechanism of accommodation by preventing the formation of the membrane attack complex (MAC) on the accommodated graft.