The Effect of Intraoperative Overdistraction on Subsidence Following Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: The purpose of this study was to evaluate the effect of overdistraction on interbody cage subsidence. BACKGROUND: Vertebral overdistraction due to the use of large intervertebral cage sizes may increase the risk of postoperative subsidence. METHODS: Patients who underwent anterior cervical discectomy and fusion between 2016 and 2021 were included. All measurements were performed using lateral cervical radiographs at 3 time points - preoperative, immediate postoperative, and final follow-up >6 months postoperatively. Anterior and posterior distraction were calculated by subtracting the preoperative disc height from the immediate postoperative disc height. Cage subsidence was calculated by subtracting the final follow-up postoperative disc height from the immediate postoperative disc height. Associations between anterior and posterior subsidence and distraction were determined using multivariable linear regression models. The analyses controlled for cage type, cervical level, sex, age, smoking status, and osteopenia. RESULTS: Sixty-eight patients and 125 fused levels were included in the study. Of the 68 fusions, 22 were single-level fusions, 35 were 2-level, and 11 were 3-level. The median final follow-up interval was 368 days (range: 181-1257 d). Anterior disc space subsidence was positively associated with anterior distraction (beta = 0.23; 95% CI: 0.08, 0.38; P = 0.004), and posterior disc space subsidence was positively associated with posterior distraction (beta = 0.29; 95% CI: 0.13, 0.45; P < 0.001). No significant associations between anterior distraction and posterior subsidence (beta = 0.07; 95% CI: -0.06, 0.20; P = 0.270) or posterior distraction and anterior subsidence (beta = 0.06; 95% CI: -0.14, 0.27; P = 0.541) were observed. CONCLUSIONS: We found that overdistraction of the disc space was associated with increased postoperative subsidence after anterior cervical discectomy and fusion. Surgeons should consider choosing a smaller cage size to avoid overdistraction and minimize postoperative subsidence.

ChatGPT versus NASS clinical guidelines for degenerative spondylolisthesis: a comparative analysis.

BACKGROUND CONTEXT: Clinical guidelines, developed in concordance with the literature, are often used to guide surgeons' clinical decision making. Recent advancements of large language models and artificial intelligence (AI) in the medical field come with exciting potential. OpenAI's generative AI model, known as ChatGPT, can quickly synthesize information and generate responses grounded in medical literature, which may prove to be a useful tool in clinical decision-making for spine care. The current literature has yet to investigate the ability of ChatGPT to assist clinical decision making with regard to degenerative spondylolisthesis. PURPOSE: The study aimed to compare ChatGPT's concordance with the recommendations set forth by The North American Spine Society (NASS) Clinical Guideline for the Diagnosis and Treatment of Degenerative Spondylolisthesis and assess ChatGPT's accuracy within the context of the most recent literature. METHODS: ChatGPT-3.5 and 4.0 was prompted with questions from the NASS Clinical Guideline for the Diagnosis and Treatment of Degenerative Spondylolisthesis and graded its recommendations as "concordant" or "nonconcordant" relative to those put forth by NASS. A response was considered "concordant" when ChatGPT generated a recommendation that accurately reproduced all major points made in the NASS recommendation. Any responses with a grading of "nonconcordant" were further stratified into two subcategories: "Insufficient" or "Over-conclusive," to provide further insight into grading rationale. Responses between GPT-3.5 and 4.0 were compared using Chi-squared tests. RESULTS: ChatGPT-3.5 answered 13 of NASS's 28 total clinical questions in concordance with NASS's guidelines (46.4%). Categorical breakdown is as follows: Definitions and Natural History (1/1, 100%), Diagnosis and Imaging (1/4, 25%), Outcome Measures for Medical Intervention and Surgical Treatment (0/1, 0%), Medical and Interventional Treatment (4/6, 66.7%), Surgical Treatment (7/14, 50%), and Value of Spine Care (0/2, 0%). When NASS indicated there was sufficient evidence to offer a clear recommendation, ChatGPT-3.5 generated a concordant response 66.7% of the time (6/9). However, ChatGPT-3.5's concordance dropped to 36.8% when asked clinical questions that NASS did not provide a clear recommendation on (7/19). A further breakdown of ChatGPT-3.5's nonconcordance with the guidelines revealed that a vast majority of its inaccurate recommendations were due to them being "over-conclusive" (12/15, 80%), rather than "insufficient" (3/15, 20%). ChatGPT-4.0 answered 19 (67.9%) of the 28 total questions in concordance with NASS guidelines (P = 0.177). When NASS indicated there was sufficient evidence to offer a clear recommendation, ChatGPT-4.0 generated a concordant response 66.7% of the time (6/9). ChatGPT-4.0's concordance held up at 68.4% when asked clinical questions that NASS did not provide a clear recommendation on (13/19, P = 0.104). CONCLUSIONS: This study sheds light on the duality of LLM applications within clinical settings: one of accuracy and utility in some contexts versus inaccuracy and risk in others. ChatGPT was concordant for most clinical questions NASS offered recommendations for. However, for questions NASS did not offer best practices, ChatGPT generated answers that were either too general or inconsistent with the literature, and even fabricated data/citations. Thus, clinicians should exercise extreme caution when attempting to consult ChatGPT for clinical recommendations, taking care to ensure its reliability within the context of recent literature.

Use of ChatGPT for Determining Clinical and Surgical Treatment of Lumbar Disc Herniation With Radiculopathy: A North American Spine Society Guideline Comparison.

OBJECTIVE: Large language models like chat generative pre-trained transformer (ChatGPT) have found success in various sectors, but their application in the medical field remains limited. This study aimed to assess the feasibility of using ChatGPT to provide accurate medical information to patients, specifically evaluating how well ChatGPT versions 3.5 and 4 aligned with the 2012 North American Spine Society (NASS) guidelines for lumbar disk herniation with radiculopathy. METHODS: ChatGPT's responses to questions based on the NASS guidelines were analyzed for accuracy. Three new categories-overconclusiveness, supplementary information, and incompleteness-were introduced to deepen the analysis. Overconclusiveness referred to recommendations not mentioned in the NASS guidelines, supplementary information denoted additional relevant details, and incompleteness indicated omitted crucial information from the NASS guidelines. RESULTS: Out of 29 clinical guidelines evaluated, ChatGPT-3.5 demonstrated accuracy in 15 responses (52%), while ChatGPT-4 achieved accuracy in 17 responses (59%). ChatGPT-3.5 was overconclusive in 14 responses (48%), while ChatGPT-4 exhibited overconclusiveness in 13 responses (45%). Additionally, ChatGPT-3.5 provided supplementary information in 24 responses (83%), and ChatGPT-4 provided supplemental information in 27 responses (93%). In terms of incompleteness, ChatGPT-3.5 displayed this in 11 responses (38%), while ChatGPT-4 showed incompleteness in 8 responses (23%). CONCLUSION: ChatGPT shows promise for clinical decision-making, but both patients and healthcare providers should exercise caution to ensure safety and quality of care. While these results are encouraging, further research is necessary to validate the use of large language models in clinical settings.

An 11-Year-Long Analysis of the Risks Associated With Age in Patients Undergoing Anterior Cervical Discectomy and Fusion in a Large, Urban Academic Hospital.

STUDY DESIGN: A retrospective database study of patients at an urban academic medical center undergoing an Anterior Cervical Discectomy and Fusion (ACDF) surgery between 2008 and 2019. OBJECTIVE: ACDF is one of the most common spinal procedures. Old age has been found to be a common risk factor for postoperative complications across a plethora of spine procedures. Little is known about how this risk changes among elderly cohorts such as the difference between elderly (60+) and octogenarian (80+) patients. This study seeks to analyze the disparate rates of complications following elective ACDF between patients aged 60-69 or 70-79 and 80+ at an urban academic medical center. METHODS: We identified patients who had undergone ACDF procedures using CPT codes 22,551, 22,552, and 22,554. Emergent procedures were excluded, and patients were subdivided on the basis of age. Then each cohort was propensity matched for univariate and univariate logistic regression analysis. RESULTS: The propensity matching resulted in 25 pairs in both the 70-79 and 80+ y.o. cohort comparison and 60-69 and 80+ y.o. cohort comparison. None of the cohorts differed significantly in demographic variables. Differences between elderly cohorts were less pronounced: the 80+ y.o. cohort experienced only significantly higher total direct cost (P = .03) compared to the 70-79 y.o. cohort and significantly longer operative time (P = .04) compared to the 60-69 y.o. cohort. CONCLUSIONS: Octogenarian patients do not face much riskier outcomes following elective ACDF procedures than do younger elderly patients. Age alone should not be used to screen patients for ACDF.

Pelvic Fixation With a Quad-Rod Technique Using S2 Alar Iliac and Medialized Entry Iliac Screws for Long Fusion Constructs.

PURPOSE: Patients with adult spinal deformity (ASD) may have risk factors for nonunion and subsequent instrumentation failure. This study reviews a novel surgical technique for a quad-rod construct to the pelvis using both S2 alar iliac (S2AI) screw fixation and medialized entry iliac screw fixation as described through three separate cases and a review of the literature. METHODS: This technique facilitates alignment of the construct and rod insertion into the tulip heads. The medialized iliac screw technique also avoids the potential soft-tissue complications of the conventional iliac screw bolt given that it is deeper and has more soft-tissue coverage. RESULTS: Three cases performed by the most senior author (V.A.) in which this novel technique was used are presented in this report along with clinical and radiographic images to educate the reader on appropriate execution of this technique. A review of the existing literature regarding pelvic fixation techniques for ASD was also done. CONCLUSION: Quad-rod augmentation of long thoracolumbar spinal constructs with two independent SI anchoring points is potentially an effective technique to increase lumbar sacral construct rigidity, thereby promoting fusion rates and decreasing revision rates. The described technique provides spine surgeons with an additional tool in their armamentarium to treat patients with complex ASD.

A Case Report of Bilateral Navicular Osteonecrosis Successfully Treated With Medial Femoral Condyle Vascularized Autografts: A Case Report.

CASE: A 17-year-old boy with a history of chronic bilateral navicular osteonecrosis with fragmentation was treated with 6-month staged bilateral open reduction and internal fixation of tarsal navicular with debridement of the necrotic bone and ipsilateral medial femoral condyle vascularized bone grafting. CONCLUSION: The patient progressed to full painless weight-bearing on each extremity by 4 months postoperatively with osseous union of both chronic fracture sites and incorporation of vascularized bone grafts. Patient-Reported Outcomes Measurement Information System (PROMIS) scores were improved from preoperative levels at 6 months from each operation. This patient's atypical presentation of a rare disease was successfully treated with the utilization of vascularized bone grafting to salvage the tarsal navicular and preserve the talonavicular joint, enabling return of function and avoidance of early arthrodesis procedure.

American Society for Surgery of the Hand (ASSH) Presidential Address Themes, 1964-2018: Revisiting Our History as We Move Forward.

The American Society for Surgery of the Hand (ASSH) was established in 1946. Since then, important advances have been made in the diagnosis and treatment of conditions affecting the upper extremity. However, there has been little documentation regarding how the largest and oldest society dedicated to hand surgery has evolved over time. Furthermore, an understanding of the history of the ASSH and the specialty of hand surgery should be emphasized in resident and fellow education. The authors aim to provide a historical overview of the ASSH through the speeches of ASSH past presidents that sheds light on future directions and long-term goals. Presidential addresses from 1961 to 2018 (courtesy of ASSH Chase Library historical archives) were reviewed. The overall percentage of ASSH presidents by specialty was 67% orthopedic, 25% plastic surgery, and 8% general surgery. The most common speech theme overall was how to be a good hand surgeon (31%). The most common speech themes were, by decade: the 1960s, history and the current state of ASSH; the 1970s and 1980s, assessments of how to be a good surgeon and goals for ASSH; the 1990s, health care and governmental regulation; the 2000s, how to be a better hand surgeon; and the 2010s goals for ASSH. In earlier years, there was more of a focus on education and technical skill development in the ASSH. Work-life balance, introduced in the 1990s, has become more of a focus in the past 20 years. Revisiting the history of the ASSH and its goals allows us to reflect on progress made while recognizing what is important as we look into the future. Furthermore, as we strive to make progress in the field of hand surgery during the current pandemic, valuable tools surface that will allow the specialty to strengthen its education, research, and patient care delivery in the future.

Point-of-Care Ultrasound Diagnosis of Multiple Mandibular Fractures in an Adolescent Presenting to the Pediatric Emergency Department.

We present a case of an adolescent patient with multiple mandibular fractures diagnosed by point-of-care ultrasound in the pediatric emergency department. Sonographic findings consistent with fracture were identified in our patient, and early consultation expedited interdepartmental coordination and disposition. The role of ultrasound in identifying various traumatic orthopedic and maxillofacial injuries is discussed.

The Zebrafish Neurophenome Database (ZND): a dynamic open-access resource for zebrafish neurophenotypic data.

Zebrafish (Danio rerio) are widely used in neuroscience research, where their utility as a model organism is rapidly expanding. Low cost, ease of experimental manipulations, and sufficient behavioral complexity make zebrafish a valuable tool for high-throughput studies in biomedicine. To complement the available repositories for zebrafish genetic information, there is a growing need for the collection of zebrafish neurobehavioral and neurological phenotypes. For this, we are establishing the Zebrafish Neurophenome Database (ZND; www.tulane.edu/∼znpindex/search ) as a new dynamic online open-access data repository for behavioral and related physiological data. ZND, currently focusing on adult zebrafish, combines zebrafish neurophenotypic data with a simple, easily searchable user interface, which allow scientists to view and compare results obtained by other laboratories using various treatments in different testing paradigms. As a developing community effort, ZND is expected to foster innovative research using zebrafish by federating the growing body of zebrafish neurophenotypic data.

The effects of chronic social defeat stress on mouse self-grooming behavior and its patterning.

Stress induced by social defeat is a strong modifier of animal anxiety and depression-like phenotypes. Self-grooming is a common rodent behavior, and has an ordered cephalo-caudal progression from licking of the paws to head, body, genitals and tail. Acute stress is known to alter grooming activity levels and disrupt its patterning. Following 15-17 days of chronic social defeat stress, grooming behavior was analyzed in adult male C57BL/6J mice exhibiting either dominant or subordinate behavior. Our study showed that subordinate mice experience higher levels of anxiety and display disorganized patterning of their grooming behaviors, which emerges as a behavioral marker of chronic social stress. These findings indicate that chronic social stress modulates grooming behavior in mice, thus illustrating the importance of grooming phenotypes for neurobehavioral stress research.

Analyzing habituation responses to novelty in zebrafish (Danio rerio).

Analysis of habituation is widely used to characterize animal cognitive phenotypes and their modulation. Although zebrafish (Danio rerio) are increasingly utilized in neurobehavioral research, their habituation responses have not been extensively investigated. Utilizing the novel tank test, we examine intra- and inter-session habituation and demonstrate robust habituation responses in adult zebrafish. Analyzing the intra-session habituation to novelty further, we also show that selected anxiogenic drugs (caffeine, pentylenetetrazole), as well as stress-inducing alarm pheromone, attenuated zebrafish habituation. Some acute anxiolytic agents, such as morphine and ethanol, while predictably reducing zebrafish anxiety, had no effects on habituation. Chronic ethanol and fluoxetine treatments improved intra-session habituation in zebrafish. In general, our study parallels literature on rodent habituation responses to novelty, and reconfirms zebrafish as a promising model for cognitive neurobehavioral research.

Modeling withdrawal syndrome in zebrafish.

The zebrafish (Danio rerio) is rapidly becoming a popular model species in behavioral neuroscience research. Zebrafish behavior is robustly affected by environmental and pharmacological manipulations, and can be examined using exploration-based paradigms, paralleled by analysis of endocrine (cortisol) stress responses. Discontinuation of various psychotropic drugs evokes withdrawal in both humans and rodents, characterized by increased anxiety. Sensitivity of zebrafish to drugs of abuse has been recently reported in the literature. Here we examine the effects of ethanol, diazepam, morphine and caffeine withdrawal on zebrafish behavior. Overall, discontinuation of ethanol, diazepam and morphine produced anxiogenic-like behavioral or endocrine responses, demonstrating the utility of zebrafish in translational research of withdrawal syndrome.