Nearly All Peer-to-Peer Reviews for CT and MRI Prior Authorization Denials for Orthopedic Specialists Are Approved.

In the event of prior authorization denial, physicians may request peer-to-peer review, which may delay treatment and increase administrative burden. The purpose of this study was to quantify the approval rate of peer-to-peer review and evaluate its efficiency in the context of advanced imaging use in an orthopedic practice. Patients at a single outpatient orthopedic clinic initially receiving an insurance denial for computed tomography or magnetic resonance imaging requiring peer-to-peer review from March to December 2022 were prospectively enrolled. Characteristics of the request, peer-to-peer review, and the reviewer and dates in the process were collected. If the study was approved after peer-to-peer review, the date of the imaging study and brief results were recorded. A total of 62 denials were included. One denial was approved prior to peer-to-peer review. Fifty-eight (of 61, 95.1%) reviews were approved, of which 51 (of 58, 87.9%) studies were completed by patients. Reviewers were always physicians (61 of 61, 100%), but of those whose specialty was known, none were orthopedic surgeons. Forty-four of 61 (72.1%) reviewers reported reviewing clinical notes in advance. The median number of days from visit to peer-to-peer review was 9.0 (interquartile range, 7.0-13.25). The median number of days from visit to imaging center appointment was 13.5 (interquartile range, 9.0-20.75) for approved studies. Of the 51 approved studies completed by patients, the results of 38 (74.5%) confirmed the suspected diagnosis. In an orthopedic specialty practice, almost all peer-to-peer reviews were approved, with the majority of the completed studies confirming the suspected diagnosis. Thus, patient care was delayed. Reform is crucial to improve the efficiency of the review process, especially in light of additional administrative and financial burden. [Orthopedics. 202x;4x(x):xx-xx.].

Evaluating the Academic Influence of Orthopedic Surgeons in Spinal Literature Through Relative Citation Ratio.

INTRODUCTION:  The innovative iCite tool applies the relative citation ratio (RCR) to gauge the time and field-adjusted scientific influence of a publication. This study examines scholarly effects on spine surgery to distinguish the impact made by orthopedic surgeons, neurosurgeons, and several other specialists. MATERIALS AND METHODS:  From 2013 to 2017, 100 of the highest RCR-rated articles were gathered for each of the following terms: cervical disc herniation (CDH), lumbar disc herniation (LDH), lumbar spinal stenosis (LSS), neurogenic claudication (NC), radiculopathy (RAD), and sciatica (SC). The first, second, and last authors were queried for background and academic qualifications and placed into the following specialty categories: orthopedic surgery, neurosurgery, pain management, medicine, and others. To provide an alternative degree of influence, the Scopus database was employed to classify the h-index associated with each author. RESULTS:  Across the six search terms, there were 526 orthopedic surgeons among 1,730 authors (30.4%), with the highest representation in LSS (118/290, 40.7%), and the lowest in SC (45/286, 15.7%). Orthopedics was the most influential specialty across all six research terms by median RCR (p = 0.012). Compared to their neurosurgical counterparts, orthopedic authors had a greater influence in CDH (3.93 vs. 2.63, p = 0.0492), LDH (5.10 vs. 4.99, p = 1.0000), NC (2.16 vs. 1.40, p = 0.2370), and SC (3.35 vs. 3.04, p = 0.5285), but had a lower influence in LSS (5.13 vs. 5.32, p = 0.7736) and RAD (5.03 vs. 6.05, p = 0.3938). CONCLUSION:  Orthopedic surgeons lead other specialties when determining scholarly influence through RCR across six of the pre-designated research domains within spine surgery. For orthopedics, a modest influence in LSS and RAD may suggest potential areas of future focus. The use of bibliometrics to analyze available literature enables us to identify other specialties that have contributed to our field and promote interdisciplinary collaboration.

The Influence of Orthopedic Journals in Knee Arthritis Treatment Research: Evaluation Using Relative Citation Ratio.

Introduction The iCite database, developed by the National Institute of Health (NIH), utilizes a bibliometric known as the relative citation ratio (RCR) to gauge scholarly impact. The goal of this study was to use the RCR to evaluate the influence of orthopedic journals in regard to knee arthritis treatment literature, as no such studies exist to date. Materials and methods The 100 highest RCR-rated articles published between 2007 and 2017 were obtained in the following categories: physical therapy (PT), viscosupplementation (VS), nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroid injection (CSI), results of total knee arthroplasty (TKA), platelet-rich plasma (PRP), and meniscectomy (MS). Journals were categorized with respect to the following specialties: general orthopedics (GO), orthopedic subspecialty (OSS), nonsurgical musculoskeletal (NSMSK), general medicine (GM), and basic science/nonclinical (BS/NC). Results Across the seven domains, GO journals held the highest median RCR, while OSS ranked fourth (RCR, 6.60 versus 3.95; p=0.0027). GO journals were considered the most influential specialty in CSI (RCR, 2.99), while OSS journals held the highest median RCR in PRP (RCR, 4.10). OSS and GO journals ranked third (RCR, 4.79) and fourth (RCR, 4.21), respectively, in NSAIDs, lagging behind NSMSK and GM journals. Conclusions Bibliometric tools, such as the RCR, can inform the orthopedic field of current and future research trends and help guide further research efforts. Currently, publications in GO journals hold a strong influence in CSI but less so in PT and NSAIDs. The use of bibliometrics allows the identification of highly influential non-orthopedic articles and journals to read while identifying influential non-orthopedic researchers to promote interdisciplinary collaboration.

Factors Associated With Repeat Emergency Department Visits for Low Back Pain.

Background Low back pain represents 2-3% of Emergency Department (ED) visits. In this study, we aimed to identify patient and treatment-related variables that contributed to repeat visits to the ED for low back pain within a 12-month period. Methodology We conducted a retrospective review of adult patients presenting to the ED of one hospital over a two-year period with the primary diagnosis of low back pain. The primary outcome included return to the ED within 12 months with the same complaint, and the secondary outcome included return to the ED within 30 days or six months. Results A total of 793 patients met the inclusion criteria. The rate of return to the ED with the same complaint within 30 days, six months, and 12 months of the first visit was 7%, 11%, and 14%, respectively. Patients who received opioids at discharge were more likely to return within 12 months (68% vs. 55%; p = 0.0075) and six months (68% vs. 56%; p = 0.0184) compared to those who did not receive opioids at discharge. Undergoing an X-ray decreased the odds of a 30-day return visit by 70% (p = 0.0067), and by 59% within 12 months (p = 0.0032). Receiving opioids at discharge also doubled the odds of return within 12 months (odds ratio = 2.030, p = 0.0183), while receiving nonsteroidal anti-inflammatory drugs (NSAIDs) reduced the odds by 60% (p = 0.0028). Conclusions Patients who received opioids at discharge were more likely to have a return visit for low back pain within six and 12 months. Patients who underwent X-rays at the index visit and were prescribed NSAIDs at discharge were less likely to return to the ED for low back pain.

Patient Satisfaction with Orthopedic Telemedicine Health Visits During the COVID-19 Pandemic.

Background:Telemedicine usage in orthopedic surgery has seen a dramatic increase as a result of the severe acute respiratory syndrome coronavirus 2 pandemic. The purpose of this study was to examine patient perceptions with telemedicine at a large orthopedic practice.Materials and Methods:An anonymous online survey was distributed to all patients who received a telemedicine health visit at our institution for musculoskeletal complaints from March 17 to June 1, 2020. Responses were scored on a 5-point Likert scale (strongly disagree, disagree, neutral, agree, and strongly agree, 1-5) and analyzed by average score and percent reaching top box.Results:A majority of patients (76.5%) were satisfied with their visit, and only 19.2% did not want telemedicine as a future option. Patients who presented for follow-up visits (4.11 vs. 3.94, p = 0.0053; 48% vs. 41%, p = 0.02) and utilized video (4.21 vs. 3.88, p < 0.001; 51% vs. 39%, p < 0.001) were more satisfied. Average satisfaction between older (>65 years) and younger patients was similar (4.06 vs. 4.06, p = 0.97), however, younger patients were more likely to reach top box (42% vs. 51%, p < 0.001). Confidence that the physician came to the correct diagnosis (r = 0.78, p < 0.001) and receiving the same information and care as an in-office visit (r = 0.60, p < 0.001) demonstrated the strongest correlation with satisfaction and desire for future telemedicine visits, respectively. Interestingly, 31.1% of patients would have sought treatment elsewhere had telemedicine not been an option.Conclusions:Overall, satisfaction rates are high for orthopedic patients undergoing telemedicine visits. Patients are more confident in telemedicine when presenting for a follow-up visit and with the use of video.

Differences in Patient and Physician Perceptions of Urgency for Musculoskeletal Conditions During the COVID-19 Pandemic.

In 2020, the coronavirus disease 2019 (COVID-19) pandemic limited musculoskeletal care to urgent or "nonelective" office visits and procedures. No guidelines exist to inform patients or physicians what meets these criteria. The purpose of this multi-institutional study was to describe the differences in perceptions of urgency for musculoskeletal complaints between patients and providers during the COVID-19 pandemic. An anonymous survey was distributed to patients who visited the authors' orthopedic clinics in January and February 2020 and practicing orthopedic surgeons. The surveys were administered in May 2020 after COVID-19 was officially labeled a pandemic and included questions regarding demographic information and perceptions of orthopedic urgency. A total of 1491 patients and 128 physicians completed the surveys. A significantly higher percentage of physicians considered the following diagnoses an appropriate indication for an urgent visit compared with patients: fracture (P<.001), acute dislocation (P<.001), infection (P<.001), neurologic compromise (P<.001), tumor (P<.001), acute tendon injury (P<.001), weakness (P<.001), inability to bear weight (P<.001), post-surgical problem (P<.001), and painful joint effusion (P<.001). There were no significant differences in the perception of urgency for the following conditions: bursitis/tendonitis (P=1.00), joint/extremity deformity without pain (P=.113), and loss of range of motion of a joint (P=.467). Younger patients and those with higher levels of education were significantly more likely to consider their conditions urgent. Patients may require additional education to prevent delay in treatment of urgent conditions-especially time-sensitive conditions such as neurologic compromise, tumors, and infections-when access to physicians is limited. [Orthopedics. 2021;44(4):e534-e538.].

Patient Perception of Physician Attire in the Outpatient Setting During the COVID-19 Pandemic.

INTRODUCTION: In response to the SARS-CoV-2 pandemic, physician attire has evolved to incorporate personal protective equipment (PPE). Although PPE is mandated for all healthcare workers, variability exists in choice and availability. The purpose of this study was to determine patient perception of physician attire during the COVID-19 pandemic in an outpatient setting. METHODS: Three hundred sixty-eight patients who presented to our outpatient orthopaedic clinics completed an anonymous survey. In addition to demographic characteristics, patient preferences for attire, PPE, and social distancing were obtained. RESULTS: Scrubs (81%, 298/368) were found to be the most acceptable physician attire. Eye protection (34.2%, 126/368) and gloves (32.6%, 120/368), however, were deemed much less acceptable; 93.5% (344/368) of patients reported that no mask was unacceptable, with 41.0% (151/368) preferring a surgical mask. Predilection for a surgical mask and N95 rose with increasing patient education level. Interestingly, 55.2% (203/368) responded that physicians should stop wearing PPE only when the Center for Disease Control recommends. CONCLUSION: During the COVID-19 pandemic, most of the patients found scrubs to be the most acceptable attire in an office-based outpatient setting. Patients also found physician mask-wearing to be important but are less accepting of providers wearing eye and hand protection.

Correlation of Early Outcomes and Intradiscal Interleukin-6 Expression in Lumbar Fusion Patients.

OBJECTIVE: To determine if there is correlation between intradiscal levels of interleukin-6 (IL-6) and early outcome measures in patients undergoing lumbar fusion for painful disc degeneration. METHODS: Intervertebral disc tissue was separated into annulus fibrosus/nucleus pulposus and cultured separately in vitro in serum-free medium (Opti-MEM). Conditioned media was collected after 48 hours. The concentration of IL-6 was quantified using enzyme-linked immunosorbent assay. Pearson correlation coefficients quantified relationships between IL-6 levels and pre- and postoperative visual analogue scale (VAS) back pain and Oswestry Disability Index (ODI), as well as change in VAS/ODI. RESULTS: Sixteen discs were harvested from 9 patients undergoing anterior lumbar interbody fusion (mean age, 47.4 years; range, 21-70 years). Mean preoperative and 6-month postoperative VAS were 8.1 and 3.7, respectively. Mean preoperative and postoperative ODI were 56.2 and 25.6, respectively. There were significant positive correlations between IL-6 expression and postoperative VAS (ρ = 0.38, p = 0.048) and ODI (ρ = 0.44, p = 0.02). No significant correlations were found between intradiscal IL-6 expression and preoperative VAS (ρ = -0.12, p = 0.54). Trends were seen associating IL-6 expression and change in VAS/ODI (ρ = -0.35 p = 0.067; ρ = -0.34, p = 0.08, respectively). A trend associated IL-6 and preoperative ODI (ρ = 0.36, p = 0.063). CONCLUSION: The direct association between IL-6 expression and VAS/ODI suggests patients with elevated intradiscal cytokine expression may have worse early outcomes than those with lower expression of IL-6 after surgery for symptomatic disc degeneration.

Does Riluzole Influence Bone Formation?: An In Vitro Study of Human Mesenchymal Stromal Cells and Osteoblast.

STUDY DESIGN: A post-test design biological experiment. OBJECTIVE: The aim of this study was to evaluate the osteogenic effects of riluzole on human mesenchymal stromal cells and osteoblasts. SUMMARY OF BACKGROUND DATA: Riluzole may benefit patients with spinal cord injury (SCI) from a neurologic perspective, but little is known about riluzole's effect on bone formation, fracture healing, or osteogenesis. METHODS: Human mesenchymal stromal cells (hMSCs) and human osteoblasts (hOB) were obtained and isolated from healthy donors and cultured. The cells were treated with riluzole of different concentrations (50, 150, 450 ng/mL) for 1, 2, 3, and 4 weeks. Cytotoxicity was evaluated as was the induction of osteogenic differentiation of hMSCs. Differentiation was evaluated by measuring alkaline phosphatase (ALP) activity and with Alizarin red staining. Osteogenic gene expression of type I collagen (Col1), ALP, osteocalcin (Ocn), Runx2, Sox9, Runx2/Sox9 ratio were measured by qRT-PCR. RESULTS: No cytotoxicity or increased proliferation was observed in bone marrow derived hMSCs and primary hOBs cultured with riluzole over 7 days. ALP activity was slightly increased in hMSCs after treatment for 2 weeks with riluzole 150 ng/mL and slightly upregulated by 150% (150 ng/mL) and 90% (450 ng/mL) in hMSCs at 3 weeks. In hOBs, ALP activity almost doubled after 2 weeks of culture with riluzole 150 ng/mL (P < 0.05). More pronounced 2.6-fold upregulation was noticed after 3 weeks of culture with riluzole at both 150 ng/mL (P = 0.05) and 450 ng/mL (P = 0.05). No significant influence of riluzole on the mRNA expression of osteocalcin (OCN) was observed. CONCLUSION: The effect of riluzole on bone formation is mixed; low-dose riluzole has no effect on the viability or function of either hMSCs or hOBs. The activity of ALP in both cell types is upregulated by high-dose riluzole, which may indicate that high-dose riluzole can increase osteogenic metabolism and subsequently accelerate bone healing process. However, at high concentrations, riluzole leads to a decrease in osteogenic gene expression, including Runx2 and type 1 collagen. LEVEL OF EVIDENCE: N/A.

The local cytokine and growth factor response to recombinant human bone morphogenetic protein-2 (rhBMP-2) after spinal fusion.

BACKGROUND CONTEXT: The systemic response regarding cytokine expression after the application of recombinant human bone morphogenetic protein-2 (rhBMP-2) in a rat spinal fusion model has recently been defined, but the local response has not been defined. Defining the local cytokine and growth factor response at the fusion site will help explain the roles of these molecules in the fusion process, as well as that of rhBMP-2. Our hypothesis is that the application of rhBMP-2 to the fusion site will alter the local levels of cytokines and growth factors throughout the fusion process, in a manner that is different from the systemic response, given the tissue-specific effects of rhBMP-2. PURPOSE: The purpose of this study was to evaluate the local cytokine and growth factor response after the application of rhBMP-2 in a rat spinal fusion model. STUDY DESIGN/SETTING: This was a basic science animal model study. METHODS: This study was partially funded by a physician-sponsored grant from Medtronic. A total of 135 Wistar rats (age 8 weeks, weighing approximately 300-400 g) underwent L4-L5 posterolateral intertransverse fusion with demineralized bone graft (approximately 0.4-cm3 rat demineralized bone matrix [DBM] per side). In the first group, 10 µg of rhBMP-2 on an allograft collagen sponge (ACS) was added to the fusion site with approximately 0.4-cm3 rat DBM per side. In the second group, 100 µg of rhBMP-2 on an ACS was added to the fusion site with approximately 0.4-cm3 rat DBM per side, and the third experiment was the control group, which consisted of only an ACS plus 0.4-cm3 DBM per side. There were nine groups of five animals each per experiment. Each group was sacrificed at time points up to 4 weeks (1, 6, 24, and 48 hours, and 4, 7, 14, 21, and 28 days after surgery). At sacrifice, the DBM, transverse processes, and any new bone formed were harvested, immediately frozen in liquid nitrogen, and prepared for protein extraction. ELISA was performed to compare the levels of various cytokines (interleukin [IL]-1ß, tumor necrosis factor alpha, IL-6, IL-1RA [IL-1 receptor antagonist], IL-4, and IL-10) and growth factors (vascular endothelial growth factor [VEGF], endothelia growth factor [EGF], insulin-like growth factor-1 [IGF-1], platelet derived growth factor [PDGF], transforming growth factor beta [TGF-ß]) that are known to be involved in the fusion-fracture healing process. Fusion was evaluated on the rats sacrificed at 28 days by manual palpation and microcomputed tomography (microCT) by two independent observers. RESULTS: The expression of cytokines and growth factors varied throughout the fusion process at each time point. In the groups treated with rh-BMP-2, IL-6 and IL-1RA had higher expression in the early time points (1 and 6 hours). Tumor necrosis factor alpha demonstrated significantly lower expression in the groups treated with rhBMP-2 at Days 1, 2, and 4. At the early time points (1 and 6 hours), in the groups treated with rhBMP-2, all of the growth factors IGF-1, VEGF, platelet derived growth factor AB (PDGF-AB), TGF-ß had equal or lower expression compared with controls. At 24 hours, there was a peak in IGF-1, VEGF, and PDGF-AB. These growth factors then declined, with IGF-1 and PDGF-AB having a second peak at Day 7. At 4 weeks, all of the rhBMP-2-treated animals fused based on manual palpation and microCT. The control group had four of five rats fused based on manual palpation and two of five rats based on microCT. CONCLUSIONS: There is significant variability in the expression of cytokines throughout the fusion process after treatment with rhBMP-2. The inflammatory response appears to peak early (1 and 6 hours), followed by a significant decrease with rhBMP-2 treatment. However, the growth factor expression appears to be suppressed early (1 and 6 hours), followed by a peak at 24 hours, and a second peak at Day 7.

Outcome of a Resident Spine Surgical Skills Training Program.

STUDY DESIGN: Cadaver training lab. OBJECTIVE: To determine if a technical cadaver skills training lab for spinal surgery increases resident confidence, satisfaction in training, and perception of operating room safety. SUMMARY OF BACKGROUND DATA: Resident training is an important topic in the setting of work hour reform. The use of supplemental materials such as videos, sawbones, and simulators may become important to adequately train orthopedic residents. At present, there are no established curricula for training orthopedic surgery residents on anatomy and common procedures encountered during a spinal surgery rotation. METHODS: Residents were assembled into teams of a PGY-5 and PGY-2 and/or PGY-1 to perform dissection and procedures on 5 fresh-frozen spine cadavers. With attending and spine fellow supervision, residents performed anterior cervical, posterior cervical, and posterior thoracolumbar surgical exposure, decompression, and fusion procedures in the operating room using surgical tools and instrumentation. Residents were then queried about their confidence levels, satisfaction in training, and perception of safety using a Likert scale (0-10). Strong agreement (scores ≥8) and strong disagreement (scores ≤3) and correlations were evaluated. RESULTS: Seventeen residents completed the training program (7 PGY-1s, 2 PGY-2s, and 8 PGY-5s). After the training, the majority of residents strongly agreed that they had an increased confidence of their own abilities (59%). A significant majority (65%) of residents strongly agreed that they were satisfied with the benefits provided by the training program. Compared with other methods of education, residents strongly agreed that the training was more helpful than textbook chapters (94%), sawbones (94%), web-based training (94%), or a virtual-based (completely electronic) training (94%). After the training, residents strongly agreed that the training improved feelings of preparation (47%), safety (41%), and ability to prevent intraoperative errors (41%). The vast majority of residents strongly agreed "Before performing surgery on me, I would want a resident to perform this cadaveric training" (88%). CONCLUSIONS: These results demonstrate that team-based, cadaveric training with adequate attending supervision, before onset of a spine surgical rotation, may lead to high resident confidence, satisfaction in training, and perception of patient safety.

Are Modic changes associated with intervertebral disc cytokine profiles?

BACKGROUND CONTEXT: Degenerative changes including Modic changes (MCs) are commonly observed in patients with chronic low back pain. Although intervertebral disc (IVD) cytokine expression has been shown to be associated with low back pain, the cytokine profile for degenerative IVD with and without MC has not been compared. PURPOSE: This study aimed to evaluate the potential association between IVD cytokine expression and MCs. STUDY DESIGN: A laboratory study was carried out. METHODS: The IVD tissue samples from 10 patients with type II MCs and10 patients without MCs who underwent an anterior lumbar interbody and fusion for significant low back pain were collected. The expression levels of 42 cytokines were determined using a RayBio Human Cytokine Antibody Array 3 (RayBiotech Inc, Norcross, GA, USA) and the results were verified with enzyme-linked immunosorbent assay (ELISA). RESULTS: The cytokine array demonstrated a statistically significant increase in the expression of granulocyte-macrophage colony-stimulating factor (GM-CSF) (p=.001) and epithelial-derived neutrophil-activating peptide 78 (ENA-78) (p=.04), and a trend toward an increase in interleukin-1ß (IL-1ß) (p=.12) and tumor necrosis factor-α (TNF-α) (p=.22) in IVDs associated with type II MCs. These results were validated with ELISA which demonstrated a 3.85-fold increase in the GM-CSF level between IVDs with type II MCs compared with those without MCs (p=.03). Similarly there was a significant increase in the level of both ENA-78 (3.68-fold, p=.02) and IL-1ß (2.11-fold, p=.01) in IVDs with type II MCs. Lastly, there was a trend (p=.07) toward an increase in TNF-α in IVDs with type II MCs (4.4-fold). CONCLUSION: Intervertebral discs with type II MCs demonstrate a significant increase in IL-1ß, GM-CSF, and ENA-78, and there is a trend toward an increase in TNF-α. These results further strengthen the association between MCs and low back pain.

The Effect of Substance P on an Intervertebral Disc Rat Organ Culture Model.

STUDY DESIGN: Laboratory study. OBJECTIVE: Evaluate the effect of substance P (SP) on an intervertebral disc rat organ culture model. SUMMARY OF BACKGROUND DATA: Monolayer cell experiments have demonstrated that exposure intervertebral disc tissue cells to SP leads to upregulation in inflammatory cytokine expression; however, this has not been evaluated in a more complex organ culture model. METHODS: Forty-eight intervertebral discs from eight rats were used in an organ culture model. Intervertebral discs were divided into three groups: control, SP-treated group, and a group treated with an SP antagonist followed by SP. Cytokine antibody array was used to quantify expression patterns, which were confirmed using ELISA and real-time polymerase chain reaction. RESULTS: The cytokine array demonstrated a 3.40 ±â€Š 0.59-fold increase in interleukin 6 (IL-6) expression in the SP group (P = 0.004), and the effect of SP was mitigated by the SP antagonist (P = 0.03). These results were verified as ELISA demonstrated a significant difference in the IL-6 level between the control group and SP group (0.73 vs. 5.80 ng/mL, P < 0.001), and there was a significant difference in the IL-6 level between the SP and the SP antagonist group (5.80 vs. 4.02 ng/mL, P = 0.01). Similarly, the real-time polymerase chain reaction demonstrated that the discs treated with SP had a 4.77-fold increase in IL-6 levels (P = 0.01) compared to controls, and a significantly greater increase in IL-6 levels between the intervertebral discs in the SP group and those in the SP antagonist group versus control (4.77 vs. 1.57, P = 0.02). CONCLUSION: SP lead to the activation of an inflammatory pathway by increasing expression of IL-6 in an intervertebral disc organ culture model. These results provide evidence that SP may be an important factor in the link between intervertebral disc degeneration and low back pain. LEVEL OF EVIDENCE: N/A.

The Thoracolumbar AOSpine Injury Score.

Study Design Survey of 100 worldwide spine surgeons. Objective To develop a spine injury score for the AOSpine Thoracolumbar Spine Injury Classification System. Methods Each respondent was asked to numerically grade the severity of each variable of the AOSpine Thoracolumbar Spine Injury Classification System. Using the results, as well as limited input from the AOSpine Trauma Knowledge Forum, the Thoracolumbar AOSpine Injury Score was developed. Results Beginning with 1 point for A1, groups A, B, and C were consecutively awarded an additional point (A1, 1 point; A2, 2 points; A3, 3 points); however, because of a significant increase in the severity between A3 and A4 and because the severity of A4 and B1 was similar, both A4 and B1 were awarded 5 points. An uneven stepwise increase in severity moving from N0 to N4, with a substantial increase in severity between N2 (nerve root injury with radicular symptoms) and N3 (incomplete spinal cord injury) injuries, was identified. Hence, each grade of neurologic injury was progressively given an additional point starting with 0 points for N0, and the substantial difference in severity between N2 and N3 injuries was recognized by elevating N3 to 4 points. Finally, 1 point was awarded to the M1 modifier (indeterminate posterolateral ligamentous complex injury). Conclusion The Thoracolumbar AOSpine Injury Score is an easy-to-use, data-driven metric that will allow for the development of a surgical algorithm to accompany the AOSpine Thoracolumbar Spine Injury Classification System.

Zinc has insulin-mimetic properties which enhance spinal fusion in a rat model.

BACKGROUND CONTEXT: Previous studies have found that insulin or insulin-like growth factor treatment can stimulate fracture healing in diabetic and normal animal models, and increase fusion rates in a rat spinal fusion model. Insulin-mimetic agents, such as zinc, have demonstrated antidiabetic effects in animal and human studies, and these agents that mimic the effects of insulin could produce the same beneficial effects on bone regeneration and spinal fusion. PURPOSE: The purpose of this study was to analyze the effects of locally applied zinc on spinal fusion in a rat model. STUDY DESIGN/SETTING: Institutional Animal Care and Use Committee-approved animal study using Sprague-Dawley rats was used as the study design. METHODS: Thirty Sprague-Dawley rats (450-500 g) underwent L4-L5 posterolateral lumbar fusion (PLF). After decortication and application of approximately 0.3 g of autograft per side, one of three pellets were added to each site: high-dose zinc calcium sulfate (ZnCaSO4), low-dose ZnCaSO4 (half of the high dose), or a control palmitic acid pellet (no Zn dose). Systemic blood glucose levels were measured 24 hours postoperatively. Rats were sacrificed after 8weeks and the PLFs analyzed qualitatively by manual palpation and radiograph review, and quantitatively by micro-computed tomography (CT) analysis of bone volume and trabecular thickness. Statistical analyses with p-values set at .05 were accomplished with analysis of variance, followed by posthoc tests for quantitative data, or Mann-Whitney rank tests for qualitative assessments. RESULTS: Compared with controls, the low-dose zinc group demonstrated a significantly higher manual palpation grade (p=.011), radiographic score (p=.045), and bone formation on micro-CT (172.9 mm(3) vs. 126.7 mm(3) for controls) (p<.01). The high-dose zinc also demonstrated a significantly higher radiographic score (p=.017) and bone formation on micro-CT (172.7 mm(3) vs. 126.7 mm(3)) (p<.01) versus controls, and was trending toward higher manual palpation scores (p=.058). CONCLUSIONS: This study demonstrates the potential benefit of a locally applied insulin-mimetic agent, such as zinc, in a rat lumbar fusion model. Previous studies have demonstrated the benefits of local insulin application in the same model, and it appears that zinc has similar effects.

Is there a regional difference in morphology interpretation of A3 and A4 fractures among different cultures?

OBJECT The aim of this study was to determine if the ability of a surgeon to correctly classify A3 (burst fractures with a single endplate involved) and A4 (burst fractures with both endplates involved) fractures is affected by either the region or the experience of the surgeon. METHODS A survey was sent to 100 AOSpine members from all 6 AO regions of the world (North America, South America, Europe, Africa, Asia, and the Middle East) who had no prior knowledge of the new AOSpine Thoracolumbar Spine Injury Classification System. Respondents were asked to classify 25 cases, including 6 thoracolumbar burst fractures (A3 or A4). This study focuses on the effect of region and experience on surgeons' ability to properly classify these 2 controversial fracture variants. RESULTS All 100 surveyed surgeons completed the survey, and no significant regional (p > 0.50) or experiential (p > 0.21) variability in the ability to correctly classify burst fractures was identified; however, surgeons from all regions and with all levels of experience were more likely to correctly classify A3 fractures than A4 fractures (p < 0.01). Further analysis demonstrated that no region predisposed surgeons to increasing their assessment of severity of burst fractures. CONCLUSIONS A3 and A4 fractures are the most difficult 2 fractures to correctly classify, but this is not affected by the region or experience of the surgeon; therefore, regional variations in the treatment of thoracolumbar burst fractures (A3 and A4) is not due to differing radiographic interpretation of the fractures.

Reliability analysis of the AOSpine thoracolumbar spine injury classification system by a worldwide group of naïve spinal surgeons.

PURPOSE: The aims of this study were (1) to demonstrate the AOSpine thoracolumbar spine injury classification system can be reliably applied by an international group of surgeons and (2) to delineate those injury types which are difficult for spine surgeons to classify reliably. METHODS: A previously described classification system of thoracolumbar injuries which consists of a morphologic classification of the fracture, a grading system for the neurologic status and relevant patient-specific modifiers was applied to 25 cases by 100 spinal surgeons from across the world twice independently, in grading sessions 1 month apart. The results were analyzed for classification reliability using the Kappa coefficient (κ). RESULTS: The overall Kappa coefficient for all cases was 0.56, which represents moderate reliability. Kappa values describing interobserver agreement were 0.80 for type A injuries, 0.68 for type B injuries and 0.72 for type C injuries, all representing substantial reliability. The lowest level of agreement for specific subtypes was for fracture subtype A4 (Kappa = 0.19). Intraobserver analysis demonstrated overall average Kappa statistic for subtype grading of 0.68 also representing substantial reproducibility. CONCLUSION: In a worldwide sample of spinal surgeons without previous exposure to the recently described AOSpine Thoracolumbar Spine Injury Classification System, we demonstrated moderate interobserver and substantial intraobserver reliability. These results suggest that most spine surgeons can reliably apply this system to spine trauma patients as or more reliably than previously described systems.

AOSpine subaxial cervical spine injury classification system.

PURPOSE: This project describes a morphology-based subaxial cervical spine traumatic injury classification system. Using the same approach as the thoracolumbar system, the goal was to develop a comprehensive yet simple classification system with high intra- and interobserver reliability to be used for clinical and research purposes. METHODS: A subaxial cervical spine injury classification system was developed using a consensus process among clinical experts. All investigators were required to successfully grade 10 cases to demonstrate comprehension of the system before grading 30 additional cases on two occasions, 1 month apart. Kappa coefficients (κ) were calculated for intraobserver and interobserver reliability. RESULTS: The classification system is based on three injury morphology types similar to the TL system: compression injuries (A), tension band injuries (B), and translational injuries (C), with additional descriptions for facet injuries, as well as patient-specific modifiers and neurologic status. Intraobserver and interobserver reliability was substantial for all injury subtypes (κ = 0.75 and 0.64, respectively). CONCLUSIONS: The AOSpine subaxial cervical spine injury classification system demonstrated substantial reliability in this initial assessment, and could be a valuable tool for communication, patient care and for research purposes.