Adolescent idiopathic scoliosis in adulthood.

Adolescent idiopathic scoliosis (AIS) is an abnormal coronal curvature of the spine that most commonly presents in adolescence. While it may be asymptomatic, AIS can cause pain, cosmetic deformity, and physical and psychological disability with curve progression. As adolescents with AIS enter adulthood, condition outcomes vary with some experiencing curve stabilization and others noting further curve progression, chronic pain, osteoporosis/fractures, declines in pulmonary and functional capacity, among others. Regular monitoring and individualized management by healthcare professionals are crucial to address the diverse challenges and provide appropriate support for a fulfilling adult life with AIS. This review examines the prevalence, risk factors, presenting symptoms, diagnosis, management, and complications of AIS in the adult population, informing targeted interventions by clinicians caring for adult patients with AIS.

Impact of Gender on Peri-Operative Characteristics and Outcomes of Lumbar Spine Surgery: A Current Concepts Review.

The success of spine surgery is variable among patients. Finding reliable predictors of successful outcomes will not only maximize patient benefit, but also increase the cost effectiveness of surgery. Recent research has demonstrated the importance of patient specific factors in predicting patient outcomes, including gender. While many studies show that female patients present with worse pain and function pre-operatively, there is conflicting data on whether male and female patients reap the same benefits from lumbar spine surgery. In this manuscript we review the current research on gender and sex differences in pre-operative characteristics and post-operative outcomes and comment on the need for more studies to better elucidate the mechanism driving the conflicting evidence.

Does the Application of Topical Vancomycin Reduce Surgical Site Infections in Spine Surgery? A Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Surgical site infections (SSIs) represent a major challenge in spine surgery, leading to severe morbidity, mortality, and increased costs. The local application of antibiotics, particularly vancomycin, has emerged as a potential strategy. Individual randomized controlled trials (RCTs) have disagreed about the efficacy of topical vancomycin in preventing SSIs after spine surgery, and so a meta-analysis that pools data from those RCTs might be helpful to inform clinicians' decisions on the topic. QUESTIONS/PURPOSES: This meta-analysis of RCTs asked: Does intrawound topical vancomycin reduce the risk of (1) SSIs, (2) deep SSIs, and (3) superficial SSIs in patients undergoing spine surgery? METHODS: PubMed, Cochrane, and Google Scholar (pages 1-20) were searched up through March 13, 2024 (search performed on March 13, 2024). Inclusion criteria consisted of English or non-English-language RCTs comparing the implementation of topical vancomycin in spine surgery to its nonuse and assessing its efficacy in preventing SSI, while exclusion criteria consisted of nonrandomized comparative studies, single-arm noncomparative studies, comparative studies based on national databases or from the same center as other included studies, studies posted to preprint servers, studies reporting incomplete/nonrelevant outcomes, and studies adding another SSI preventive measure. The studies were assessed using the Cochrane Risk of Bias tool. Heterogeneity was evaluated by Q tests and I2 statistics. We used a random-effects model when considerable heterogeneity was observed (all SSIs, deep SSIs); otherwise, a fixed-effects model was used (all SSIs subanalysis, superficial SSIs). Furthermore, the fragility index was calculated for each of the assessed outcomes when there was no difference between the two groups to assess how many patients were needed to experience the outcomes for a difference to become present. The studied outcomes were the risks of SSIs, deep SSIs, and superficial SSIs. Deep SSIs were defined by the included trials as SSIs underneath the fascia, otherwise they were considered superficial. Six RCTs representing a total of 2140 patients were included, with 1053 patients in the vancomycin group and 1087 in the control group. Using an alpha of 0.05, our meta-analysis had 80% power to detect a risk difference of 1.5% for the primary outcome between patients who did and did not receive vancomycin. The age of the patients in the vancomycin group ranged from 37 to 52 years, while the age in the control group ranged from 34 to 52 years. The surgical procedures consisted of both instrumented and noninstrumented spinal procedures. Overall, the risk of bias in the included studies was either low or unclear, with none of the studies having a high risk of bias in any of the assessed categories (selection bias, performance bias, detection bias, attrition bias, and reporting bias). RESULTS: We found no difference in the risk of SSI between the vancomycin and control groups (3.0% [32 of 1053] versus 3.9% [42 of 1087], relative risk 0.74 [95% CI 0.35 to 1.57]; p = 0.43). Ten additional patients (4.8% infection risk) in the control group would need to experience an SSI for a difference to be observed between the two groups. We found no difference in the risk of deep SSI between the vancomycin and control groups (1.8% [15 of 812] versus 2.7% [23 of 860], relative risk 0.69 [95% CI 0.24 to 2.00]; p = 0.50). Seven additional patients (3.5% infection risk) in the control group would need to experience a deep SSI for a difference to be observed between the two groups. We found no difference in the risk of superficial SSI between the vancomycin and control groups (1.0% [6 of 620] versus 1.4% [9 of 662], relative risk 0.68 [95% CI 0.25 to 1.89]; p = 0.46). Seven additional patients (2.4% infection risk) in the control group would need to experience a superficial SSI for a difference to be observed between the two groups. CONCLUSION: This meta-analysis of randomized trials examining use of topical vancomycin in spine surgery failed to show efficacy in reducing infection, and thus we do not recommend routine use of topical vancomycin for this indication. Future large-scale trials would be needed if surgeons believe that between-group differences smaller than those for which we were powered here (this meta-analysis had 80% power to detect a between-group difference of 1.5% in infection risk) are clinically important, and large database surveys may be informative in terms of assessing for postoperative adverse events associated with the use of vancomycin powder. LEVEL OF EVIDENCE: Level I, therapeutic study.

Segmental Sagittal Alignment in Lumbar Spinal Fusion: A Review of Evidence-Based Evaluation of Preoperative Measurement, Surgical Planning, Intraoperative Execution, and Postoperative Evaluation.

BACKGROUND AND OBJECTIVES: Maintaining and restoring global and regional sagittal alignment is a well-established priority that improves patient outcomes in patients with adult spinal deformity. However, the benefit of restoring segmental (level-by-level) alignment in lumbar fusion for degenerative conditions is not widely agreed on. The purpose of this review was to summarize intraoperative techniques to achieve segmental fixation and the impact of segmental lordosis on patient-reported and surgical outcomes. METHODS: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, PubMed, Embase, Cochrane, and Web of Science databases were queried for the literature reporting lumbar alignment for degenerative lumbar spinal pathology. Reports were assessed for data regarding the impact of intraoperative surgical factors on postoperative segmental sagittal alignment and patient-reported outcome measures. Included studies were further categorized into groups related to patient positioning, fusion and fixation, and interbody device (technique, material, angle, and augmentation). RESULTS: A total of 885 studies were screened, of which 43 met inclusion criteria examining segmental rather than regional or global alignment. Of these, 3 examined patient positioning, 8 examined fusion and fixation, 3 examined case parameters, 26 examined or compared different interbody fusion techniques, 5 examined postoperative patient-reported outcomes, and 3 examined the occurrence of adjacent segment disease. The data support a link between segmental alignment and patient positioning, surgical technique, and adjacent segment disease but have insufficient evidence to support a relationship with patient-reported outcomes, cage subsidence, or pseudoarthrosis. CONCLUSION: This review explores segmental correction's impact on short-segment lumbar fusion outcomes, finding the extent of correction to depend on patient positioning and choice of interbody cage. Notably, inadequate restoration of lumbar lordosis is associated with adjacent segment degeneration. Nevertheless, conclusive evidence linking segmental alignment to patient-reported outcomes, cage subsidence, or pseudoarthrosis remains limited, underscoring the need for future research.

Laminoplasty Versus Laminectomy and Posterior Fusion for Cervical Myelopathy: A Meta-analysis of Radiographic and Clinical Outcomes.

STUDY DESIGN: Meta-analysis. OBJECTIVE: This meta-analysis investigates the outcomes of laminoplasty (LP) and laminectomy with fusion (LF) to guide effective patient selection for these two procedures. BACKGROUND: While LF traditionally offers the ability for excellent posterior decompression, it may alter cervical spine biomechanics and increase the risk of adjacent segment degeneration. LP aims to preserve the natural kinematics of the spine but has not been universally accepted, and may be associated with inadequate decompression, neck pain, and recurrent stenosis. METHODS: PubMed, Cochrane, and Google Scholar (Pages 1-20) were searched up until March 2024. The outcomes studied were surgery-related outcomes (operating room (OR) time, estimated blood loss (EBL), and length of stay (LOS)), adverse events (overall complications, C5 palsy, and reoperations), radiographic outcomes (cervical lordosis (CL), cervical sagittal vertical axis (cSVA), and T1 slope angle (T1SA)), and patient-reported outcome measures (PROMs) (Neck Disability Index (NDI), Visual Analog Scale (VAS) for neck pain, and Japanese Orthopaedic Association (JOA)). RESULTS: Twenty-two studies were included in this meta-analysis, of which 19 were retrospective studies, two were prospective non-randomized studies, and one was a randomized controlled trial. A total of 2,128 patients were included, with 1,025 undergoing LP and 1,103 undergoing LF. LP patients experienced significantly shorter OR time (P=0.009), less EBL (P=0.02), a lower rate of overall complications (P<0.00001) and C5 palsy (P=0.003), a lower T1SA (P=0.02), and a lower NDI (P=0.0004). No significant difference was observed in the remaining outcomes. CONCLUSION: This meta-analysis demonstrates that for cervical myelopathy, LP has the benefits of shorter OR time, less EBL, and reduced incidence of C5 palsy as well as overall complication rate. Given these findings, LP remains an important surgical option with a favorable complication profile in patients with cervical myelopathy, although careful patient selection is still paramount in choosing the right procedure for individual patients.

Cutibacterium acnes in spine surgery: pathophysiology, diagnosis, and treatment.

Cutibacterium acnes (C. acnes) previously named Propionibacterium acnes (P. acnes) has been increasingly recognized by spine surgeons as a cause of indolent post-surgical spinal infection. Patients infected with C. acnes may present with pseudarthrosis or nonspecific back pain. Currently, microbiological tissue cultures remain the gold standard in diagnosing C. acnes infection. Ongoing research into using genetic sequencing as a diagnostic method shows promising results and may be another future way of diagnosis. Optimized prophylaxis involves the use of targeted antibiotics, longer duration of antibiotic prophylaxis, antibacterial-coated spinal implants, and evidence-based sterile surgical techniques all of which decrease contamination. Antibiotics and implant replacement remain the mainstay of treatment, with longer durations of antibiotics proving to be more efficacious. Local guidelines must consider the surge of antimicrobial resistance worldwide when treating C. acnes.

Management of traumatic spinal cord injury: A current concepts review of contemporary and future treatment.

Spinal Cord Injury (SCI) is a condition leading to inflammation, edema, and dysfunction of the spinal cord, most commonly due to trauma, tumor, infection, or vascular disturbance. Symptoms include sensory and motor loss starting at the level of injury; the extent of damage depends on injury severity as detailed in the ASIA score. In the acute setting, maintaining mean arterial pressure (MAP) higher than 85 mmHg for up to 7 days following injury is preferred; although caution must be exercised when using vasopressors such as phenylephrine due to serious side effects such as pulmonary edema and death. Decompression surgery (DS) may theoretically relieve edema and reduce intraspinal pressure, although timing of surgery remains a matter of debate. Methylprednisolone (MP) is currently used due to its ability to reduce inflammation but more recent studies question its clinical benefits, especially with inconsistency in recommending it nationally and internationally. The choice of MP is further complicated by conflicting evidence for optimal timing to initiate treatment, and by the reported observation that higher doses are correlated with increased risk of complications. Thyrotropin-releasing hormone may be beneficial in less severe injuries. Finally, this review discusses many options currently being researched and have shown promising pre-clinical results.

Management of Thoracolumbar Vertebral Fractures and Dislocations in Patients with Ankylosing Conditions of the Spine.

Ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) are bone-forming spinal conditions which inherently increase spine rigidity and place patients at a higher risk for thoracolumbar fractures. Due to the long lever-arm associated with their pathology, these fractures are frequently unstable and may significantly displace leading to catastrophic neurologic consequences. Operative and non-operative management are considerations in these fractures. However conservative measures including immobilization and bracing are typically reserved for non-displaced or incomplete fractures, or in patients for whom surgery poses a high risk. Thus, first line treatment is often surgery which has historically been an open posterior spinal fusion. Recent techniques such as minimally invasive surgery (MIS) and robotic surgery have shown promising lower complication rates as compared to open techniques, however these methods need to be further validated.

Variability in expenses related to spine oncology care: comparison of payer-negotiated rates at National Cancer Institute-Designated Cancer Centers.

BACKGROUND: As of 2021, the Centers for Medicare and Medicaid Services (CMS) requires all hospitals to publish their commercially negotiated prices. To our knowledge, price variation of spine oncology diagnosis and treatments has not been previously investigated. PURPOSE: The aim of this study is to characterize the availability and variation of prices for spinal oncology services among National Cancer Institute-Designated Cancer Centers (NCI-DCC). STUDY DESIGN: Cross-sectional analysis. METHODS: Cancer centers were identified; those that did not provide patient care or participate in Medicare's Inpatient Prospective System were excluded. A cross-sectional analysis was conducted to gather commercially negotiated prices by searching online for "[center name] price transparency OR machine-readable file OR chargemaster." Data obtained was queried using 44 current procedural terminology (CPT) codes for imaging, procedures, and surgeries relevant to spine oncology. Comparison of prices was achieved by normalizing the median price for each service at each center to the estimated 2022 Medicare reimbursement for the center's Medicare Administrator Contractor. The ratios between the lowest and highest median commercial negotiated price within a center and across all centers were defined as "within-center ratio" and "across-center ratio" respectively. RESULTS: In total, 49 centers disclosed commercial payer-negotiated rates. Mean rate (±SD) for cervical corpectomy was $9,134 (±$10,034), thoracic laminectomy for neoplasm excision was $5,382 (±$5502), superficial bone biopsy was $1,853 (±$1,717), and single-photon emission computerized tomography (SPECT) was $813 (±$232). Within-center ratios ranged from 5.0 (SPECT scan) to 17.8 (radiofrequency bone ablation). Across-center ratios (for codes with > 10 centers reporting) ranged from 9.0 (corpectomy, thoracic, lateral extra-cavitary) to 418.7 (anterior approach cervical corpectomy). CONCLUSIONS: Price transparency for spinal oncology remains elusive despite recent CMS regulatory oversight, with marked heterogeneity in the quality of published rates complicating patients' ability to "shop" for care. Additionally, there continues to be significant variation in commercial rates for spine oncology diagnosis and treatment. CLINICAL SIGNIFICANCE: Despite regulation by CMS, prices for spinal oncology services are not uniformly available to patients and vary between NCI-DCC. The findings of this manuscript present potential barriers for patients to compare and obtain affordable care.

Assessing the Accuracy and Reliability of AI-Generated Responses to Patient Questions Regarding Spine Surgery.

BACKGROUND: In today's digital age, patients increasingly rely on online search engines for medical information. The integration of large language models such as GPT-4 into search engines such as Bing raises concerns over the potential transmission of misinformation when patients search for information online regarding spine surgery. METHODS: SearchResponse.io, a database that archives People Also Ask (PAA) data from Google, was utilized to determine the most popular patient questions regarding 4 specific spine surgery topics: anterior cervical discectomy and fusion, lumbar fusion, laminectomy, and spinal deformity. Bing's responses to these questions, along with the cited sources, were recorded for analysis. Two fellowship-trained spine surgeons assessed the accuracy of the answers on a 6-point scale and the completeness of the answers on a 3-point scale. Inaccurate answers were re-queried 2 weeks later. Cited sources were categorized and evaluated against Journal of the American Medical Association (JAMA) benchmark criteria. Interrater reliability was measured with use of the kappa statistic. A linear regression analysis was utilized to explore the relationship between answer accuracy and the type of source, number of sources, and mean JAMA benchmark score. RESULTS: Bing's responses to 71 PAA questions were analyzed. The average completeness score was 2.03 (standard deviation [SD], 0.36), and the average accuracy score was 4.49 (SD, 1.10). Among the question topics, spinal deformity had the lowest mean completeness score. Re-querying the questions that initially had answers with low accuracy scores resulted in responses with improved accuracy. Among the cited sources, commercial sources were the most prevalent. The JAMA benchmark score across all sources averaged 2.63. Government sources had the highest mean benchmark score (3.30), whereas social media had the lowest (1.75). CONCLUSIONS: Bing's answers were generally accurate and adequately complete, with incorrect responses rectified upon re-querying. The plurality of information was sourced from commercial websites. The type of source, number of sources, and mean JAMA benchmark score were not significantly correlated with answer accuracy. These findings underscore the importance of ongoing evaluation and improvement of large language models to ensure reliable and informative results for patients seeking information regarding spine surgery online amid the integration of these models in the search experience.

Anterior cervical discectomy and fusion versus cervical disc arthroplasty: an epidemiological review of 433,660 surgical patients from 2011 to 2021.

BACKGROUND CONTEXT: Anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) are commonly performed operations to address cervical radiculopathy and myelopathy. Trends in utilization and revision surgery rates warrant investigation. PURPOSE: To explore the epidemiology, postoperative complications, and reoperation rates of ACDF and CDA. DESIGN: Retrospective cohort study. PATIENT SAMPLE: A total of 433,660 patients who underwent ACDF or CDA between 2011 and 2021 were included in this study. OUTCOME MEASURES: The following data were observed for all cases: patient demographics, complications, and revisions. METHODS: The PearlDiver database was queried to identify patients who underwent ACDF and CDA between 2011 and 2021. Epidemiological analyses were performed to examine trends in cervical procedure utilization by age group and year. After matching by age, sex, Charlson Comorbidity Index (CCI), levels of operation, and reason for surgery, the early postoperative (2-week), short-term (2-year), and long-term (5-year) complications of both cervical procedures were examined. RESULTS: In total, 404,195 ACDF and 29,465 CDA patients were included. ACDF utilization rose by 25.25% between 2011 and 2014 while CDA utilization rose by 654.24% between 2011-2019 followed by relative plateauing in both procedures. Mann-Kendall trend test confirmed a significant but small rise in ACDF and large rise in CDA procedures from 2011 to 2021 (p<.001). After matching, ACDF and CDA had an overall complication rate of 12.20% and 8.77%, respectively, with the most common complications being subsequent anterior revision (4.96% and 3.35%) and dysphagia (3.70% and 2.98%). The ACDF cohort, especially multilevel ACDF patients, generally had more complications and higher revision rates than the CDA cohort (p<.05). CONCLUSIONS: While ACDF utilization has plateaued since 2014, CDA rates have risen by a staggering 654.24% over the past decade. ACDF and CDA complication and revision rates were relatively low in comparison to previously published values, with significantly lower rates in CDA. Although a lack of radiographic data in this study limits its power to recommend either procedure for individual patients with cervical radiculopathy or myelopathy, CDA may be associated with minor improvement in the complication and revision profile.

Sacroplasty for Sacral Insufficiency Fractures: Narrative Literature Review on Patient Selection, Technical Approaches, and Outcomes.

Sacral insufficiency fractures commonly affect elderly women with osteoporosis and can cause debilitating lower back pain. First line management is often with conservative measures such as early mobilization, multimodal pain management, and osteoporosis management. If non-operative management fails, sacroplasty is a minimally invasive intervention that may be pursued. Candidates for sacroplasty are patients with persistent pain, inability to tolerate immobilization, or patients with low bone mineral density. Before undergoing sacroplasty, patients' bone health should be optimized with pharmacotherapy. Anabolic agents prior to or in conjunction with sacroplasty have been shown to improve patient outcomes. Sacroplasty can be safely performed through a number of techniques: short-axis, long-axis, coaxial, transiliac, interpedicular, and balloon-assisted. The procedure has been demonstrated to rapidly and durably reduce pain and improve mobility, with little risk of complications. This article aims to provide a narrative literature review of sacroplasty including, patient selection and optimization, the various technical approaches, and short and long-term outcomes.

Sagittal Alignment in the Degenerative Lumbar Spine: Surgical Planning.

➤ Sagittal alignment of the spine has gained attention in the field of spinal deformity surgery for decades. However, emerging data support the importance of restoring segmental lumbar lordosis and lumbar spinal shape according to the pelvic morphology when surgically addressing degenerative lumbar pathologies such as degenerative disc disease and spondylolisthesis.➤ The distribution of caudal lordosis (L4-S1) and cranial lordosis (L1-L4) as a percentage of global lordosis varies by pelvic incidence (PI), with cephalad lordosis increasing its contribution to total lordosis as PI increases.➤ Spinal fusion may lead to iatrogenic deformity if performed without attention to lordosis magnitude and location in the lumbar spine.➤ A solid foundation of knowledge with regard to optimal spinal sagittal alignment is beneficial when performing lumbar spinal surgery, and thoughtful planning and execution of lumbar fusions with a focus on alignment may improve patient outcomes.

Utilization of Antibiotic Bone Cement in Spine Surgery: Pearls, Techniques, and Case Review.

Vertebral osteomyelitis (VO) encompasses a spectrum of spinal infections ranging from isolated mild vertebral osteomyelitis to severe diffuse infection with associated epidural abscess and fracture. Although patients can often be treated with an initial course of intravenous antibiotics, surgery is sometimes required in patients with sepsis, spinal instability, neurological compromise, or failed medical treatment. Antibiotic bone cement (ABC) has been widely used in orthopedic extremity surgery for more than 150 years, both for prophylaxis and treatment of bacterial infection. However, relatively little literature exists regarding its utilization in spine surgery. This article describes ABC utilization in orthopedic surgery and explains the technique of ABC utilization in spine surgery. Surgeons can choose from multiple premixed ABCs with variable viscosities, setting times, and antibiotics or can mix in antibiotics to bone cements themselves. ABC can be used to fill large defects in the vertebral body or disc space or in some cases to coat instrumentation. Surgeons should be wary of complications such as ABC extravasation as well as an increased difficulty with revision. With a thorough understanding of the properties of the cement and the methods of delivery, ABC is a powerful adjunct in the treatment of spinal infections.

Delayed cerebrospinal fluid (CSF) leak following anterior cervical discectomy and fusion surgery.

Background: An uncommon complication of anterior cervical discectomy and fusion (ACDF) is dura tear, which may be further complicated by cerebral spinal fluid (CSF) leak. Dural tears with CSF leak can lead to catastrophic neurologic outcomes and should be recognized early. Case Description: This case report describes a 43-year-old female patient with history of Ehlers-Danlos syndrome who presented 1-year post-ACDF with positional headaches and lightheadedness. Imaging revealed ACDF plate subsidence and CSF leak with inferior displacement of the cerebellar tonsils. Outcome: The patient underwent a revision procedure with removal of index screws and CSF repair using epidural blood patch, fat graft, and Tisseel. The original bicortical screws were replaced with shorter larger diameter unicortical screws. Post-operative imaging at 2 and 6 weeks confirmed resolution of CSF leak. Conclusions: Healthcare professionals and patients undergoing spinal surgery should be aware of late presentation CSF leaks which can represent gradual decline in neurological function. Surgical candidates at risk to develop CSF leaks should be counseled about possible complications in preoperative planning.

Longitudinal Assessment of Modern Spine Surgery Training: 10-Year Follow-up of a Nationwide Survey of Residency and Spine Fellowship Program Directors.

Spine surgeons complete training through residency in orthopaedic surgery (ORTH) or neurosurgery (NSGY). A survey was conducted in 2013 to evaluate spine surgery training. Over the past decade, advances in surgical techniques and the changing dynamics in fellowship training may have affected training and program director (PD) perceptions may have shifted. Methods: This study is a cross-sectional survey distributed to all PDs of ORTH and NSGY residencies and spine fellowships in the United States. Participants were queried regarding characteristics of their program, ideal characteristics of residency training, and opinions regarding the current training environment. χ2 tests were used to compare answers over the years. Results: In total, 241 PDs completed the survey. From 2013 to 2023, NSGY increased the proportion of residents with >300 spine cases (86%-100%) while ORTH remained with >90% of residents with < 225 cases (p < 0.05). A greater number of NSGY PDs encouraged spine fellowship even for community spine surgery practice (0% in 2013 vs. 14% in 2023, p < 0.05), which continued to be significantly different from ORTH PDs (∼88% agreed, p > 0.05). 100% of NSGY PDs remained confident in their residents performing spine surgery, whereas ORTH confidence significantly decreased from 43% in 2013 to 25% in 2023 (p < 0.05). For spinal deformity, orthopaedic PDs (92%), NSGY PDs (96%), and fellowship directors (95%), all agreed that a spine fellowship should be pursued (p = 0.99). In both 2013 and 2023, approximately 44% were satisfied with the spine training model in the United States. In 2013, 24% of all PDs believed we should have a dedicated spine residency, which increased to 39% in 2023 (fellowship: 57%, ORTH: 38%, NSGY: 21%) (p < 0.05). Conclusion: Spine surgery training continues to evolve, yet ORTH and neurological surgery training remains significantly different in case volumes and educational strengths. In both 2013 and 2023, less than 50% of PDs were satisfied with the current spine surgery training model, and a growing minority believe that spine surgery should have its own residency training pathway. Level of Evidence: IV.

Spinal Cord Stimulators and Intrathecal Pain Pump Removal Versus Retention During Posterior Lumbar Fusion: A Matched Cohort Analysis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine risks associated with posterior lumbar arthrodesis after spinal cord stimulator (SCS) and intrathecal pain pump (IPP) insertion. SUMMARY OF BACKGROUND DATA: SCS and IPPs aid in the management of chronic back and radicular pain. Little is known regarding the risks of subsequent fusion with these devices in place. METHODS: The PearlDiver Mariner database was queried for spinal fusion between 2010 and 2020. Study groups were created for indwelling SCS or IPP and matched to a separate cohort without SCS or IPP. Subgroups were created for those who had their device removed and those who retained their device at the time of surgery. Complications up to 2 years postoperatively were reviewed and confounding variables were controlled using multivariable logistic regression. RESULTS: Four thousand five hundred three patients had an indwelling SCS/IPP and underwent posterior lumbar fusion. Compared with patients without history of an SCS/IPP, patients undergoing a lumbar fusion with an SCS/IPP which was removed or retained had higher rates of revision surgery at 1 year [7.3% vs. 5.0%, odds ratio (OR) =1.48, P <0.001] and 2 year (10.8% vs. 7.0%, OR =1.59, P <0.001). For all time intervals, there were higher odds of instrumentation failure (2 y: OR =1.65, P <0.001), and pulmonary complications (2 y: OR =1.18, P <0.001). At 2 years, there were higher odds of surgical site complications (OR 1.15, P =0.02) and urinary complications (OR=1.07, P =0.04). There were no differences in complications up to 2 years postoperatively in patients with an SCS/IPP who had their devices retained or removed ( P >0.05). CONCLUSIONS: Patients with a history of spinal cord stimulators and intrathecal pain pumps are at increased risk of mechanical complications and revision fusion compared with patients without these devices. Patients with an SCS or IPP have similar rates of complications during lumbar fusion whether the device is removed or retained.

Adult Spinal Deformity Correction in Patients with Parkinson Disease: Assessment of Surgical Complications, Reoperation, and Cost.

BACKGROUND: Parkinson disease (PD) is a neurodegenerative disorder that manifests with postural instability and gait imbalance. Correction of spinal deformity in patients with PD presents unique challenges. METHODS: The PearlDiver database was queried between 2010 and 2020 to identify adult patients with spinal deformity before undergoing deformity correction with posterior spinal fusion. Two cohorts were created representing patients with and without a preoperative diagnosis of PD. Outcome measures included reoperation rates, surgical technique, cost, surgical complications, and medical complications. Multivariable logistic regression adjusting for Charlson Comorbidity Index, age, gender, 3-column osteotomy, pelvic fixation, and number of levels fused was used to assess rates of reoperation and complications. RESULTS: In total, 26,984 patients met the inclusion criteria and were retained for analysis. Of these patients, 725 had a diagnosis of PD before deformity correction. Patients with PD underwent higher rates of pelvic fixation (odds ratio [OR], 1.33; P < 0.001) and 3-column osteotomies (OR, 1.53; P < 0.001). On adjusted regression, patients with PD showed increased rates of reoperation at 1 year (OR, 1.37; P < 0.001), 5 years (OR, 1.32; P < 0.001), and overall (OR, 1.33; P < 0.001). Patients with PD also experienced an increased rate of medical complications within 30 days after deformity correction including deep venous thrombosis (OR, 1.60; P = 0.021), pneumonia (OR, 1.44; P = 0.039), and urinary tract infections (OR, 1.54; P < 0.001). Deformity correction in patients with PD was associated with higher 90-day cost (P = 0.007). CONCLUSIONS: Patients with PD undergoing long fusion for deformity correction are at significantly increased risk of 30-day medical complications and revision procedures after 1 year, controlling for comorbidities, age, and invasiveness. Surgeons should consider the risk of complications, subsequent revision procedures, and increased cost.

Adjacent Segment Disease After Spinal Fusion.

¼ Adjacent segment disease is characterized by a degenerative process adjacent to a previously fused spine segment, with new onset of clinical symptoms such as radiculopathy, myelopathy, or instability.¼ Etiology is related to the natural history of the disease process, increased biomechanical stress at adjacent segments, clinical factors specific to the individual patient, intraoperative factors, and malalignment.¼ Treatment is usually nonoperative, but surgical intervention can be indicated. Decompression and fusion remain the mainstay of operative treatment, and isolated decompression should be considered in specific cases.¼ Further randomized controlled trials are needed to establish how the treatment should progress, particularly with the development of minimally invasive and endoscopic surgery.