Accuracy of Rod Contouring to Desired Angles With and Without a Template: Implications for Achieving Desired Spinal Alignment and Outcomes.

STUDY DESIGN: Biomechanical Study. OBJECTIVE: The search for optimal spinal alignment has led to the development of sophisticated formulas and software for preoperative planning. However, preoperative plans are not always appropriately executed since rod contouring during surgery is often subjective and estimated by the surgeon. We aimed to assess whether rods contoured to specific angles with a French rod bender using a template guide will be more accurate than rods contoured without a template. METHODS: Ten experienced spine surgeons were requested to contour two 125 × 5.5 mm Ti64 rods to 40°, 60° and 80° without templates and then 2 more rods using 2D metallic templates with the same angles. Rod angles were then measured for accuracy and compared. RESULTS: Average angles for rods bent without a template to 40°, 60° and 80° were 60.2°, 78.9° and 97.5°, respectively. Without a template, rods were overbent by a mean of 18.9°. When using templates of 40°, 60° and 80°, mean bend angles were 41.5°, 59.1° and 78.7°, respectively, with an average underbend of 0.2°. Differences between the template and non-template groups for each target angle were all significant (p < 0.001). CONCLUSIONS: Without the template, surgeons tend to overbend rods compared to the desired angle, while surgeons improved markedly with a template guide. This tendency to overbend could have significant impact on patient outcomes and risk of proximal junctional failure and warrants further research to better enable surgeons to more accurately execute preoperative alignment plans.

Early outcomes and safety of outpatient (surgery center) vs inpatient based L5-S1 Anterior Lumbar Interbody Fusion.

We seek to determine the outcomes of patients undergoing outpatient-based ALIF compared to a consecutive series of inpatient based ALIF performed during the same time period. 58 consecutive patients at a single outpatient surgery center underwent ALIF from June 2015 - August 2017 and 79 ALIF's were performed at 2 Inpatient hospitals. Electronic medical records were reviewed for perioperative and postoperative complications as well as secondary interventions. 62 patients met inclusion criteria (29 Outpatient, 33 Inpatient). The inpatient group was significantly older (44 vs 51; p = 0.01). There were 8 postoperative complications. There was no difference in secondary interventions; 28 patients underwent a total of 36 interventions postoperatively for pain. Secondary interventions were performed at an average of 128(outpatient) and 158(inpatient) days (p = 0.55). There was no difference in outcome scores between the inpatient/outpatient groups at any time. Patients receiving a secondary intervention showed no significant improvement in Back VAS scores but, demonstrated a strong trend (p = 0.06) towards leg pain improvement. Patients who did not undergo secondary intervention had significant improvement in both Back and Leg VAS scores at all time points (p < 0.05). Outpatient ALIF is a safe and reproducible procedure with complication rates consistent with or lower than published rates. Patients outcome scores were no different in the inpatient versus outpatient group. Interestingly, there was a high number of secondary interventions performed in both groups. Patients undergoing a secondary procedure did not get statistically significant improvement in Back VAS but, demonstrated a strong trend in Leg VAS patient reported outcome scores.

Differentiating cervical spine and shoulder pathology: common disorders and key points of evaluation and treatment.

Accurately diagnosing patients with self-described pain in the shoulder or cervical spine (neck) remains a challenge for the orthopaedic surgeon. The overlapping presentations of shoulder disorders with those of the cervical spine, along with a lack of precision in physical examination testing, can create a confusing clinical picture and may result in disorganized or ineffective diagnostic and treatment regimens. A careful physical examination combined with judicious use of adjunctive tests, including selective corticosteroid injections, may help clarify the diagnosis. A high index of suspicion for the presence of cervical spine pathology is recommended in patients presenting with shoulder pain and vice versa.

A systematic review of definitions and classification systems of adjacent segment pathology.

STUDY DESIGN: Systematic review. OBJECTIVE: To undertake a systematic review to determine how "adjacent segment degeneration," "adjacent segment disease," or clinical pathological processes that serve as surrogates for adjacent segment pathology are classified and defined in the peer-reviewed literature. SUMMARY OF BACKGROUND DATA: Adjacent segment degeneration and adjacent segment disease are terms referring to degenerative changes known to occur after reconstructive spine surgery, most commonly at an immediately adjacent functional spinal unit. These can include disc degeneration, instability, spinal stenosis, facet degeneration, and deformity. The true incidence and clinical impact of degenerative changes at the adjacent segment is unclear because there is lack of a universally accepted classification system that rigorously addresses clinical and radiological issues. METHODS: A systematic review of the English language literature was undertaken and articles were classified using the Grades of Recommendation Assessment, Development, and Evaluation criteria. RESULTS.: Seven classification systems of spinal degeneration, including degeneration at the adjacent segment, were identified. None have been evaluated for reliability or validity specific to patients with degeneration at the adjacent segment. The ways in which terms related to adjacent segment "degeneration" or "disease" are defined in the peer-reviewed literature are highly variable. CONCLUSION: On the basis of the systematic review presented in this article, no formal classification system for either cervical or thoracolumbar adjacent segment disorders currently exists. CONSENSUS STATEMENT: No recommendations regarding the use of current classification of degeneration at any segments can be made based on the available literature. A new comprehensive definition for adjacent segment pathology (ASP, the now preferred terminology) has been proposed in this Focus Issue, which reflects the diverse pathology observed at functional spinal units adjacent to previous spinal reconstruction and balances detailed stratification with clinical utility. A comprehensive classification system is being developed through expert opinion and will require validation as well as peer review. Strength of Statement: Strong.

Infectious pin complication rates in halo vest fixators using ceramic versus metallic pins.

STUDY DESIGN: Retrospective review of database patients. OBJECTIVE: To compare infectious pin complication rates utilizing ceramic pins, an emerging technology, with a large database of complications in halo's using metallic pins. SUMMARY OF BACKGROUND DATA: The halo/vest fixator remains a useful modality of treatment for cervical spine trauma but has been described as having a high incidence of complications, foremost pin-related complications. Ceramic pins and vest modifications have been introduced under the premise of (1) decreasing pin-tract infections compared with metallic pins manufactured from stainless steel or titanium and with the advent of 3T MRI, (2) decreasing brain MRI artifact, and (3) lowering MRI intolerance owing to material overheating. MATERIAL AND METHODS: We retrospectively reviewed a prospectively collected patient data set of the Harborview Medical Center spine trauma registry. A historic control group exclusively utilizing metallic halo pins over a 10-year period was compared with patients who were treated with halo's exclusively utilizing ceramic pins over a recent 14-month period. Complications investigated included aseptic, loosening, and infections graded on a novel 3-tier system adapted from external fixation in long bone and periarticular trauma. Inclusion criteria were the patients with traumatic cervical spine injuries treated with a halo for a period of at least 14 days. RESULTS: Forty-four patients were available for analysis in the ceramic pin group versus 263 in the metallic pin group. Overall pin complications amounted to 40.9% ceramic (C) versus 21.7% metal (M) pins (P<0.05), aseptic loosening rates 13.7% (C) compared with 8.3% (M), and pin site infections 27.3% (C) compared with 13.3% (M) (P<0.05). A grading system for halo pin tract infections was developed. In assessing overall complications and infections specifically, ceramic pins seemed to be associated with a higher incidence of adverse events or complications compared with titanium pins. CONCLUSION: Despite the imbalance of size of our cohort groups, there seems to be a strong trend toward the newer ceramic pin technology not meeting expected minimum performance standards set by the earlier metallic material. Causes for the higher failure rate likely lay in the necessary changes made to the halo vest and specifically the pin design owing to the inherent mechanical property limitations of MRI compatible materials.