Rate Of Neurologic Injury Research Articles

Fracture-dislocations of the subaxial cervical spine

Fracture-dislocations of the subaxial cervical spine are rare yet potentially devastating injuries often associated with high-energy trauma. These inherently unstable injuries frequently lead to neurologic compromise, necessitating urgent operative intervention. This review provides a comprehensive overview of subaxial cervical spine fracture-dislocations, addressing their epidemiology, anatomy, and classification systems. Classification schemes including Allen and Ferguson, Cervical Spine Injury Severity Score (CSISS), Subaxial Cervical Spine Injury Classification System (SLIC), and AO Spine Subaxial Cervical Spine Injury Classification System are discussed. Prompt recognition and management of these injuries is critical in optimizing long-term functional and neurologic outcomes. Rates of neurologic injury can exceed 50 %, with distractive flexion injuries and bilateral facet injuries often presenting with higher ASIA grades and lower neurologic recovery potential. Minimizing time to reduction is the most important factor in optimizing neurologic outcomes in these injury patterns. We discuss both closed and open reduction methods, timing considerations, technical pearls, and potential complications associated with each strategy. We also discuss the diagnosis and management of concurrent acute disk herniations, the role of advanced imaging, and the debated utility of pre-reduction MRI. Many subaxial cervical fracture-dislocations necessitate surgical intervention, which can be approached from an anterior, posterior, or combined approach. Although no standard surgical treatment algorithm exists, we discuss surgical options and situations where a preferred approach may exist. Selection of the approach depends on injury characteristics and surgeon preference, and there are no clearly defined surgical recommendations based on injury pattern.

Is the Use of Intraoperative Neuromonitoring Justified During Lumbar Anterior Approach Surgery?

Intraoperative neuromonitoring (IONM) became widely used in spine surgery to reduce the risk of iatrogenic nerve injury. However, the proliferation of IONM has fallen into question based on effectiveness and costs, with a lack of evidence supporting its benefit for specific spine surgery procedures. The purpose of this study was to evaluate the use of IONM and the rate of neurological injury associated with anterior lumbar spinal surgery. This was a retrospective study on a consecutive series of 359 patients undergoing lumbar anterior approach surgery for anterior lumbar interbody fusion (ALIF), total disc replacement (TDR), or hybrid (ALIF with TDR) for the treatment of symptomatic disc degeneration. Patients undergoing any posterior spine surgery were excluded. Operative notes were reviewed to identify any changes in IONM and the surgeon's response. Clinic notes were reviewed up to 3 months postoperatively for indications of iatrogenic nerve injury. There were 3 aberrant results with respect to IONM. Changes in IONM of a lower extremity occurred for 1 patient (0.3%). The surgeon evaluated the situation and there was no observable reason for the IONM change. Upon waking, the patient was found to have no neurological deficit. There were 2 cases of neurologic deficits in this population, which were classified as false-negatives of IONM (0.56%, 95% CI: 0.1% to 1.8%). In both cases, the patients were found to have a foot drop after the anterior approach surgery. In this study, there was 1 false-positive and 2 false-negative results of IONM. These data suggest that IONM is not beneficial in this population. However, many surgeons may feel obligated to use IONM for medicolegal reasons. There is a need for future studies to delineate cases in which IONM is beneficial and the type of monitoring to use, if any, for specific spine surgery types. This study questions the routine use of IONM in anterior lumbar approach surgery for the treatment of symptomatic disc degeneration. This has significant implications related to the cost of this practice.

Transdural Ventral Sling Technique for Calcified Thoracic Disk Herniations

BackgroundSurgery for thoracic disc herniations remains an ongoing challenge, with a variety of surgical approaches, all with their own inherent risks. Discectomy via a posterior laminectomy was historically the treatment of choice; however, it was deemed very high risk with elevated rates of neurologic injury. The posterior transdural approach is an alternative surgical option for soft and calcified thoracic disc herniations. ObjectiveTo present a surgical technique to remove a calcified thoracic disc herniation without entry into the thoracic cavity. MethodsA 56-year-old female presented with many years of numbness/tingling in her hands and difficulty with fine motor tasks but developed progressive weakness and loss of balance in her legs. Imaging revealed a prominent focal central calcified disc herniation at the T5-T6 level causing severe effacement and distortion of the spinal cord. A posterior transdural approach for direct visualization of a large, calcified disc herniation was performed to remove the calcified disc herniation without the need for extensive surgical exposure or entry into the thoracic cavity. A ventral sling of the dura was created to allow rotation of the spinal cord while removing the calcified disc. Preoperative and postoperative radiographic assessments were conducted to evaluate the effectiveness of the approach. ConclusionsThe transdural approach is less invasive in nature, minimizes surgical exposure, patient morbidity, and provides better intraoperative control of the spinal cord. This constitutes an effective alternative surgical approach to both soft and calcified central thoracic disc herniations.

Ballistic injuries of the humerus: A matched cohort analysis

Introduction Ballistic fractures of the humerus secondary to gunshot wounds are increasingly common injuries that pose challenges for orthopedic surgeons. The primary purpose of this study was to examine the rates of neurovascular injury, compartment syndrome, and infection of ballistic humerus fractures relative to blunt, non-penetrating fractures. Methods A consecutive cohort of 135 patients with ballistic humerus fractures and 167 patients with blunt humerus fractures treated at a level 1 trauma center were identified. A review of patient medical records and radiographic studies was performed to obtain demographic information, injury mechanism, fracture location, choice of treatment, and complications. Statistical analysis was performed using independent sample t-tests, chi-square tests, and odds ratios ( p < 0.05 significance). Results Compared with blunt fractures, patients in the ballistic fracture cohort were younger, male, African American, test positive for illicit drug use, and sustain proximal fractures. Ballistic fractures had significantly lower Injury Severity Scores and New Injury Severity Scores. Ballistic fractures were three times as likely to present with neurovascular injury than blunt fractures (OR: 2.927, p < 0.001). The overall rate of spontaneous recovery of significant motor function for ballistic fractures with neurologic injury was 55%. There were no statistically significant differences in rates of vascular injury, compartment syndrome, infection, non-union, or the need for soft tissue reconstruction. Conclusion Compared with blunt humeral fractures, ballistic fractures appear to have a significantly higher rate of neurologic injury but no increased risk for compartment syndrome or infection. Surgical treatment of ballistic humeral injuries was not associated with increased neurological recovery compared to non-operatively managed fractures.

A comparison of bilateral and unilateral cerebral perfusion for total arch replacement surgery for non-marfan, type A aortic dissection.

Acknowledging lacking of consensus exist in total aortic arch (TAA) surgery for acute type A aortic dissection (AAD), this study aimed to investigate the neurologic injury rate between bilateral and unilateral cerebrum perfusion on the specific population. A total of 595 AAD patients other than Marfan syndrome receiving TAA surgery since March 2013 to March 2022 were included. Among them, 276 received unilateral cerebral perfusion (via right axillary artery, RCP) and 319 for bilateral cerebral perfusion (BCP). The primary outcome was neurologic injury rate. Secondary outcomes were 30-day mortality, serum inflammation response (high sensitivity C reaction protein, hs-CRP; Interleukin-6, IL-6; cold-inducible RNA binding protein, CIRBP) and neuroprotection (RNA-binding motif 3, RBM3) indexes. The BCP group reported a significantly lower permanent neurologic deficits [odds ratio: 0.481, Confidence interval (CI): 0.296-0.782, p = 0.003] and 30-day mortality (odds ratio: 0.353, CI: 0.194-0.640, p < 0.001) than those received RCP treatment. There were also lower inflammation cytokines (hr-CRP: 114 ± 17 vs. 101 ± 16mg/L; IL-6: 130 [103,170] vs. 81 [69,99] pg/ml; CIRBP: 1076 [889, 1296] vs. 854 [774, 991] pg/ml, all p < 0.001), but a higher neuroprotective cytokine (RBM3: 4381 ± 1362 vs 2445 ± 1008pg/mL, p < 0.001) at 24h after procedure in BCP group. Meanwhile, BCP resulted in a significantly lower Acute Physiology, Age and Chronic Health Evaluation (APACHE) Ⅱscore (18 ± 6 vs 17 ± 6, p < 0.001) and short stay in intensive care unit (4 [3,5] vs. 3 [2,3] days, p < 0.001) and hospital (16 ± 4 vs 14 ± 3days, p < 0.001). This present study indicated that BCP compared with RCP was associated with lower permanent neurologic deficits and 30-day mortality in AAD patients other than Marfan syndrome receiving TAA surgery.

Single intrauterine death in twin pregnancy: Evidenced-based counselling and management.

Twins have a significantly higher risk of stillbirth, preterm delivery, perinatal morbidity and mortality. Single intrauterine fetal death is a relatively common and devastating occurrence for families and clinicians alike. Monochorionic twins are up to 13 times more likely to suffer an intrauterine death when compared to singletons. Additionally, longer term neurological sequelae affect monochorionic twins disproportionately. The timing of the death of the co-twin and the fetal order at the time of death have an impact on the outcome for the survivor. The risk in dichorionic pregnancies is lower with respect to neurological injury; however, the risk of prematurity remains high, particularly where the leading twin dies in utero. Recent published studies report lower rates of neurological injury in monochorionic twin pregnancies that incur an intrauterine fetal death after foetoscopic laser ablation for twin-to-twin transfusion syndrome - an important finding for patient counselling. TWEETABLE ABSTRACT: Single intrauterine fetal death in twins is a relatively common and devastating occurrence for families and clinicians alike. Adhering to collegiate guidelines will likely reduce but not eliminate the incidence of SIUD in twins.

Cerebral protection using deep hypothermic circulatory arrest versus retrograde cerebral perfusion for aortic hemiarch reconstruction.

With evolutions in technique, recent data encourage the use of cerebral perfusion during aortic arch repair. However, a randomized data have demonstrated higher rates of neurologic injury according to MRI lesions using antegrade cerebral perfusion during hemiarch reconstruction. This was a retrospective review of two institutional aortic center databases to identify adult patients who underwent aortic hemiarch reconstruction for elective aortic aneurysm or acute type A aortic dissection. Patients were stratified according to cerebral protection method: (1) deep hypothermic circulatory arrest (DHCA)group versus (2) DHCA/retrograde cerebral perfusion (RCP) group. A total of 320 patients and 245 patients underwent hemiarch reconstruction for aortic aneurysm electively and aortic dissection, respectively. In aneurysmal pathology, the DHCA group included 133 patients and the DHCA/RCP group included 187 patients. Operative mortality was 0.8% in the DHCA group and 2.7% in the DHCA/RCP group (p = 0.41). Kaplan-Meier survival estimates revealed comparable 2-year survival (p = 0.14). In dissection, 43 patients and 202 patients were included in the DHCA group and the DHCA/RCP group, respectively. Operative mortality was equivalent between the two groups (11.6% in the DHCA group and 9.4% in the DHCA/RCP group, p = 0.58). Long-term survival was similar at 2 years between the groups (p = 0.06). Multivariable analysis showed cerebral perfusion strategy was not associated with the composite outcome of operative mortality and stroke. In treating both elective and acute ascending aortic pathologies with hemiarch reconstruction, both DHCA alone or in combination with RCP yield comparable results.

P152. Vertebral fractures and neurological injury associated with increased recreational vehicle use

<h3>BACKGROUND CONTEXT</h3> Recreational vehicle use has become increasingly popular over the past decade. The global all-terrain vehicle market size was valued at 3.9 billion USD in 2018 and is expected to grow at a rate of 3.1% between 2019 and 2025. Those who suffer accidents while using such vehicles are prone to spinal injury. However, few have examined this relationship at the national scale. <h3>PURPOSE</h3> The goal of this study was to investigate the trends between recreational vehicle use and spinal injury nationwide. <h3>STUDY DESIGN/SETTING</h3> This was a retrospective study reviewing the number of spinal injury cases involved with recreational vehicle use nationwide, utilizing the NEISS (National Electronic Injury Surveillance System) database. <h3>PATIENT SAMPLE</h3> This study isolated spinal injury cases associated with recreational vehicles, ranging from bicycles to four wheeled ATVs, two wheeled ATVs, and other all-terrain vehicles, and evaluated the rate of neurological injury and vertebral fractures in these cases. <h3>OUTCOME MEASURES</h3> Measures evaluated included proportions of vertebral fractures and nerve injuries related to recreational vehicle use. <h3>METHODS</h3> National estimates, standard errors, and 95% confidence intervals were derived using the provided survey parameters in the NEISS database. Crude rate was defined as number of cases per 100,000 persons. Significance was determined using adjusted Wald tests, for which p<.05 (2-sided) were considered significant. Proportions of fracture and nerve injury by recreational vehicle were determined by Pearson's Chi-Squared Test between bicycles, four wheeled ATVs, two wheeled ATVs, and other all-terrain, recreational vehicles. <h3>RESULTS</h3> A total of 56,349 spine injuries related to recreational vehicle use were isolated from the database. Injuries located in the lower trunk/lumbar vertebrae were most common (47.9%). A total of 78.0% of all spine injuries were experienced by males. Between 2010 and 2019, there was an increase in national cases of spine injury involving recreational vehicles (p<0.00001). Nerve injury was more prevalent in four wheeled ATVs (10.2%) when compared to all-terrain vehicles and two wheeled powered vehicles (2.93%) (p<0.0001). Lumbar spine injury, despite being the most prevalent region of spine injury, showed lower odds (p<0.0001) of being admitted. <h3>CONCLUSIONS</h3> With the increasing popularity of recreational vehicles, there is high concern for traumatic spinal injury. This study was able to identify increasing numbers of spinal injury related to such vehicle use. Such injuries are not trivial and lead to not only life-altering limitations for patients but also increasing health care costs. Physicians and patients alike should remain aware and discuss the potential harms regarding the use of recreational vehicles and their high risk for spinal injury. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

92. Complications of cervical epidural steroid injections

<h3>BACKGROUND CONTEXT</h3> Cervical epidural steroid injections (CESIs) are common in the diagnosis and treatment of cervical pathology. Rare and catastrophic complications have been reported, although prior studies have been limited by the paucity of cases. This study investigated the incidence of, and predictors for, severe procedural and medical complications associated with CESIs using deidentified national administrative claims data. <h3>METHODS</h3> The IBM® MarketScan® Commercial Claims and Encounters and Medicare Supplemental databases (2007-2015) were retrospectively analyzed. Each CESI was recorded for patients age 18 or older with active enrollment for at least one year before and 90 days after injection. Patients with neoplasm, fracture, infection, inflammatory spondyloarthropathy or cervical surgery within one year preceding the injection were excluded. If a second CESI occurred before a complication, that complication was attributed to the second injection to avoid double-counting. Multivariable repeated measures logistic regression models evaluated relationships between demographics, comorbidities, and diagnoses, and overall complication rates at 2, 7, 30 and 90 days. The patient was treated as the repeated factor to adjust for patients having multiple CESIs. Each time point was modeled separately, and level of significance was Bonferroni-adjusted for 4 time points (α=0.05/4=0.0125). <h3>RESULTS</h3> A total of 448,209 CESIs were included (age 52.2 ± 11.3 years, 57.1% female). At least one additional CESI had been performed within the prior year in 48.1% of patients. Complications totaled 1.7% 7 days following CESI with fewer procedural (0.6%) than medical complications (1.2%). Complications increased to 8.1% by 90 days, driven by medical complications (7.5%). Only 0.3% of patients required admission within 7 days. Direct root/cord injury (0.3%), stroke (0.2%), and dysrhythmia (0.5%) were predominant within 7 days of CESI. Other procedural complications were identified but remained rare. Overall complication risk within 7 days of CESI was most strongly associated with CHF [OR (95% CI): 3.08 (2.72, 3.49); p<0.001], increasing age [OR: 3.05 (2.34, 3.99) for the oldest vs youngest age groups; p<0.001], existing neurologic deficits [OR: 1.82 (1.65, 2.00); p<0.001], and transforaminal approach [OR: 1.22 (1.12, 1.34)]. Multiple procedure-related diagnoses, cardiac comorbidities, diabetes, obesity, tobacco use and southern US residence were also associated with increased complications. Results from 90-day models were similar. Neurologic complications, including both direct injuries and strokes, were most strongly predicted by existing neurologic deficits (OR: 1.93 [1.73, 2.15]; p<0.001), and were also related to transforaminal approach, increasing age, multiple procedure-related diagnoses and medical comorbidities. Most direct injuries were reported within 7 days, while stroke rates increased at each time point. Myelopathy was not associated with neurologic injury. Overall complication rates did not change significantly by year from 2007-2015, although neurologic injury rates decreased slightly (OR: 0.97 [0.96, 0.99]; p<0.001). <h3>CONCLUSIONS</h3> While complications following CESIs are rare, catastrophic complications were identified. Neurologic injuries were the most frequent procedural complications and were most strongly associated with prior neurologic deficits. Multiple factors associated with procedural and medical complications were identified. Overall complication rates did not change by year, emphasizing the need to improve safety in at-risk patients and minimize catastrophic complications. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Two-Incision Distal Biceps Repair with Cortical Button: A Technique to Improve Supination Strength

Tears of the distal biceps are common, and nonoperative treatment results in significant loss of supination strength. Surgery is indicated for most patients to restore this supination strength. Both 1- and 2-incision techniques are successful, but each has its own advantages and disadvantages. We believe the 2-incision technique better restores the anatomic attachment site of the tendon, which leads to better supination strength and has a lower rate of neurologic injury. Although it does have a slightly higher risk of synostis, this can be mitigated by routine prophylaxis with NSAIDs. Augmenting the repair with a cortical button has been shown to increase the load-to-failure better than the traditional 2-incision technique that employs transosseous fixation. Here we present our technique of 2-incision distal biceps repair with cortical button, a technique intended to maximize supination strength.

Gunshot-Related Upper Extremity Nerve Injuries at a Level 1 Trauma Center

Gunshot wounds can result in a spectrum of injuries to nerves, with little data to guide definitive treatment. We performed a retrospective evaluation of gunshot-related upper extremity injuries in an urban trauma center to analyze epidemiology, associated injuries, and short-term outcomes. We hypothesized that gunshot-related injuries would involve soft tissue cavitation, inducing axonotmesis and neuropraxia rather than neurotmesis injuries. All patients over the age of 16 with upper extremity gunshot trauma from May 2018 to May 2019 were identified through the University of Chicago orthopaedic and general surgery trauma databases. Initial nerve injuries were identified by physical examination. Patient demographic data, soft tissue and skeletal injury, treatment modality, and return of function were collected. Ballistic injuries in 1302 patients were treated over 12 months. We identified 126 upper extremity gunshot injuries in 117 patients. Thirty-eight upper extremities (38 patients) had a documented nerve deficit (38/126, 30%) with a follow-up rate of 94% (34/36) at a mean of 351 days after injury (median, 202 days; range, 13-929 days). One patient had a subacute transradial amputation, and 1 patient was deceased at final follow-up. The presence of vascular injury and fracture increased the rate of neurologic injury after gunshot injuries. At the most recent follow-up, 68% (23/34) of patients with upper extremity injury had improvement in nerve function as measured by objective clinical assessment, with 24% (8/34) experiencing full recovery at an average of 368 days (median, 261 days; range, 41-929 days). Nerve injury after ballistic trauma to the upper extremity is common. Vascular injury and fractures were associated with a higher risk of nerve injury. Short-term improvement in nerve function was seen in over half the cohort, suggesting a predominance of neuropraxic effects. Prognostic IV.

Characterization of complex vertebral transposition (gamma deformity) > 180 degrees: clinical and radiographic outcomes of halo gravity traction and vertebral column resection (VCR).

Prospective case series OBJECTIVE: Results of surgical treatment of complex vertebral transposition "Gamma Deformity" > 180 degrees with halo gravity traction (HGT) and vertebral column resection (VCR). We recently published a novel classification system for complex spine deformities of which complex vertebral transposition > 180 degrees (Gamma; type 3) was described. Halo gravity traction (HGT) has been shown to mitigate surgical risk in complex spine deformity correction and in some cases obviates the need for three-column osteotomy. However, we are not aware of report of its utilization in treating Gamma deformities with or without vertebral column resection (VCR). A consecutive series of 13 patients with Gamma deformity (GD) were prospectively enrolled at a single site in West Africa. Standard radiographs and 3D computerized tomography (CT) were done to assess coronal and sagittal vertebral transposition (CVT and SVT). The HGT with 50% of body weight was applied over several weeks followed by VCR. Demographics, operative data, radiographic parameters, and complications data were collected. 13 pts with GD underwent HGT for an avg of 110days prior to definitive surgery. Etiologies were Congenital-11 pts and Neurofibromatosis-2 pts. Average age: 17.8years; Pts were reviewed at 3months post-op and at minimum 2-year follow-up. Preop myelopathy was present in five patients. Pre-op CVT avg 75% and was corrected in all cases post-op. SVT avg 211deg and improved with HGT by 36% and corrected to 53deg (74% correction) post-op. Thoracic kyphosis avg -42deg and averaged 48deg post-op. Intra-op spinal cord monitoring (SCM) alerts occurred in 8 pts (61%). Post-operative LEM deficits occurred in 5 pts: 2 fully recovered by 3months and 2year follow-up, while the remaining 3 improved but had residual motor deficits at final follow-up. There was one post-operative mortality. The management of complex vertebral transposition (Gamma deformity) > 180 degrees with HGT prior to VCR is not only effective in some patients, but also associated with high SCM alerts and neurologic injury rates. Myelopathic patients with thoracic deformities are at higher risk of developing permanent neurologic deficits. Surgeons should be aware of this rare and unusual deformity and consider HGT and VCR bearing in mind the technical challenges and high complication rate.

P139. High rate of mortality after spinal trauma in patients with ankylosing spondylitis

BACKGROUND CONTEXT Spinal trauma in patients with Ankylosing Spondylitis (AS) often result in devastating injuries, as minor insult can manifest in spinal instability and spinal cord injury. Initial diagnostics include CT and MRI of the injured spinal region, which may indicate need for surgery. The significance of radiological findings and subsequent need for surgery in this challenging injury is not well described. PURPOSE The purpose of this study was to describe radiological findings in patients with AS sustaining spinal injuries and to analyze rate of neurologic injury, radiologic canal compromise and in-hospital mortality. STUDY DESIGN/SETTING Multicenter retrospective analysis. PATIENT SAMPLE Eighty-one patients with ankylosing spondylitis sustaining spinal trauma. OUTCOME MEASURES Rates of neurologic injury, radiologic canal compromise, in-hospital mortality, cause of death. METHODS Patients with AS (identified in radiology report) sustaining spinal injuries identified by CT or MRI were retrospectively reviewed from two level 1 trauma hospitals. Patients with prior spine surgery were excluded. CT and MRI studies at the time of injury were reviewed for fracture pattern (AO classification), ligamentous disruption, and evidence of canal compromise >50% (fracture displacement, epidural hematoma, disc herniation). Patient records were reviewed for injury mechanism, neurological status (radiculopathy, weakness, or paresthesias), need for surgical fixation, and in-hospital mortality. RESULTS A total of 81 patients with AS sustaining spine trauma were identified (mean age: 69 years, SD: 14.9; 80.2% male). Twenty-nine patients (35.8%) presented with neurological symptoms (ASIA D: 11 patients, C: 4 patients, B: 4 patients, A:5 patients). Seventy patients (86.4%) reported low-energy mechanism of injury (ground level falls). 65 patients (91.5%) sustained no associated injuries. Ankylosis of the entire spine was observed on CT in 77 patients (95.1%). AO Spine Type C injury was most common (52.1%). Fracture involving all three columns were identified on CT in 64 patients (79.0%). Three-column injury was identified on four additional patients on MRI, increasing overall three-column injury diagnosis to 68 patients (84.0%). Fracture displacement on CT causing canal compromise was observed in 40 patients (49.4%). Among patients without fracture displacement on CT causing canal compromise, 10 additional patients were observed to have canal compromise on MRI from hematoma or disc herniation increasing overall canal compromise to 50 patients (61.7%). Among patients who underwent MRI, 89.7% of patients were observed to have anterior longitudinal ligamentous injury and 75.4% were observed to have posteroligamentous complex injury. Fifty-eight patients (71.6%) underwent surgical fixation (51 patients posterior approach, 7 patients combined anterior posterior approach). Overall, in-hospital mortality rate was 8.6% (7 patients), with cause of death attributable to aspiration pneumonia in four cases. CONCLUSIONS In this multi-institutional series of 81 patients with AS sustaining spinal trauma, 7 in 10 patients required surgical fixation and nearly 1 in 10 patients expired in the hospital. Despite the vast majority of injuries being attributed to be low-energy falls, 79.0% of patients sustained three-column injuries, 61.7% of patients were observed to have canal compromise or evidence of cord compression, and 35.8% of patients presented with neurological compromise. Spine surgeons should be aware that severity of injury on CT as well as mortality may be under-estimated in this patient population. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Impact of Pediatric Subspecialty Training on Perioperative Complications in Adolescent Idiopathic Scoliosis Surgery.

This was a retrospective study of data prospectively collected from 2012 to 2016 from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. The objective was to evaluate the effect of pediatric fellowship training on 30-day perioperative morbidity and mortality following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Several pathways exist in North America by which physicians acquire the clinical and technical skills to manage AIS surgically. Previous work has noted that surgeons with pediatric fellowship training tend to perform the bulk of pediatric spine surgeries. However, no study has been performed that examines if pediatric fellowship training (PFT) has an impact on early postoperative outcomes. A total of 14,194 AIS surgical patients were identified from the ACS NSQIP database. A cohort receiving isolated PSF was abstracted from this group and separated into 3 groups according to surgeon training: (1) ped+ (with PFT, n=4455); (2) ped-(without PFT, n=325); and (3) ped+match (patients selected from ped+ matched to ped- for age, sex, and fusion levels, n=325). The groups were compared for 30-day perioperative morbidity and mortality. No significant differences were noted for the 3 groups in terms of wound infections, length of hospital stay, readmissions, and unplanned returns to the operating room. Ped+match and ped- groups had no difference in neurologic injury rates. However, the ped+ and ped+match groups had significantly lower rates of blood transfusion and average volume of blood lost compared with the ped- group. Surgeons with pediatric fellowship training have a significantly lower average blood loss volume and blood transfusion rate in PSF for AIS than surgeons without such training. Understanding that different training pathways for surgeons may directly impact operative outcomes invites further examination of surgical education in North America to improve training consistency. [Orthopedics. 2020;43(5):e454-e459.].

A Comparison of Complications and Clinical and Radiologic Outcome Between the Mini-open Prepsoas and Mini-open Transpsoas Approaches for Lumbar Interbody Fusion

Systematic review and meta-analysis. To compare complication rates and clinical and radiologic outcome between the mini-open prepsoas and mini-open transpsoas approaches for lateral lumbar interbody fusion. Both approaches are believed to be safe with similar complication rates. Previous studies suggest that the rate of neurological injury might be higher in the transpsoas group, whereas visceral or vascular injury might be more frequent in the prepsoas group. A systematic review of the literature was performed. Data were extracted from original publications up until December 26, 2018. Evidence was extracted from well-designed case-control or cohort studies and sorted in 2 groups, the prepsoas and transpsoas approaches. A meta-analysis was performed using a random-effects model (I statistic >50% for all analyses). A total of 115 studies included data of 13,260 patients, 2450 in the prepsoas group and 10,810 in the transpsoas group. Demographics for prepsoas versus transpsoas group were (N-weighted means): age 61.9 versus 60.9 years; %female sex 53% versus 63%, levels fused 1.4 versus 2.6, blood loss 52.4 versus 122.3 mL, and operating time 125.1 versus 200.7 min. The following statistically significant differences in complication rates between prepsoas and transpsoas approaches were found: transient psoas weakness or thigh/groin numbness 4% versus 26% [95% confidence interval (CI): 11%-17%], motor neural injury 0.4% versus 1.3% (95% CI: 16%-62.3%); no statistically significant differences were found for: major vascular injury 2% versus 1% (95% CI: 1.04%-2.31%), kidney or ureter injury 0.04% versus 0.08% (95% CI: 0.057%-5.2%), injury pleural/peritoneal structures 0.6% versus 0.2% (95% CI: 0.89%-6.58%), cage subsidence 5% versus 4% (95% CI: 0.9%-1.97%), surgical site infection 1% versus 1% (95% CI: 0.57%-1.66%), abdominal wall pseudohernia 1% versus 1% (95% CI: 0.07%-21.22%), sympathetic chain injury 5% versus 0% (95% CI: 0.34%-97.86%), and directly procedure-related death 0.04% versus 0% (95% CI: 0.127%-76.8%). Pooled mean perioperative changes between prepsoas and transpsoas approaches were: segmental sagittal Cobb angle 3.07 versus 1.99 degrees; foraminal height 2 versus 6.96 mm. The prepsoas had fewer complications than the transpsoas approach. Furthermore, the prepsoas approach showed superior restoration of segmental lordosis, whereas foraminal height restoration was superior with the transpsoas approach. This could be explained by the differences in location of the interbody device placement in relation to the center of rotation of the spine between the 2 surgical techniques.

Targeted Temperature Management in Post-Cardiac Arrest Patients.

Cardiac arrest occurs in over 550,000 patients every year in the United States. Survival to hospital discharge occurs in only 12% of arrests, regardless of rhythm, and many survivors experience complications such as anoxic brain injury and poor neurologic function after cardiac arrest. Post cardiac arrest hyperthermia is associated with poor outcomes, including increased mortality and rates of neurologic injury.

Deep Peroneal Nerve Injury Following Hardware Removal for Lisfranc Joint Injury.

Surgical exposure of the Lisfranc joint complex is within close proximity to the deep peroneal nerve, which can be injured in this approach. Common clinical practice is to remove Lisfranc hardware at 3 to 4 months postoperatively. However, it is unknown if this provides a clinical benefit or risks injury to the deep peroneal nerve. The rate of nerve injury is currently unknown from the published literature. This study clarifies rates of neurological injury to the deep peroneal nerve during primary surgery and hardware removal. This retrospective study was performed on all patients of a single surgeon from 2012 to 2018. Fixation was performed with locking plates or screws depending on the injury pattern. All patients who required open reduction and internal fixation routinely underwent hardware removal during this time. Neurological injury was assessed in a binary fashion (normal or abnormal) at 2, 6, and 12 weeks after the primary surgery and 2 and 12 weeks after hardware removal. McNemar's test was performed to compare the rates of injury. Patients were contacted at a minimum follow-up of 15 months (range, 15-87 months) to assess persistent nerve injury and satisfaction. Fifty-seven patients with an average age of 29.8 years were included in the final analysis; all had documentation at 3 months postsurgery. All patients had normal neurology before surgery. The rate of nerve injury for the primary surgery (11%) was significantly lower than the rate for patients with nerve injury following hardware removal (23%). However, the rate of spontaneous neurological recovery was low, with symptoms persisting in 5 of 6 patients between the primary operation and subsequent hardware removal. When these patients were excluded from the analysis, the rate of new nerve injury following hardware removal (15%) was not significantly different from the primary surgery rate. Seventy-one percent of nerve injuries persisted at the minimum 15-month final follow-up, with all patients with nerve injury being very or partially satisfied. The rate of deep peroneal nerve injury from primary Lisfranc fixation was 11%, and when routine hardware removal was planned the overall rate of nerve injury rose to 23%. This may be useful information during the patient consent process. Level IV, case series.

Avoiding Neurological Complications of Elbow Arthroscopy

Elbow arthroscopy is an increasingly common procedure performed in orthopaedic surgery. However, due to the presence of several major neurovascular structures in close proximity to the operative portals it can have potentially devastating complications. The largest series of elbow arthroscopies to date described a 2.5% rate of neurological injury after elbow arthroscopy. All of these injuries were transient nerve injuries and resolved without intervention. A recent report of major nerve injuries after elbow arthroscopy demonstrated that these injuries are likely under-reported in the literature. A retrospective review of the medical records was performed at our institutions for patients who had undergone elbow arthroscopy and had documented neurological deficits post-operatively. Charts were analyzed for the original indication for elbow arthroscopy, the documented neurological injury, and any additional surgeries undertaken to address these injuries. A review of our records from 1998 to 2014 revealed six patients who had undergone elbow arthroscopy and developed neurological injury post-operatively. Four out of the six patients (66%) had a documented permanent posterior interosseous nerve (PIN) palsy. Two out of six patients (33%) developed a permanent ulnar nerve palsy. While complications after elbow arthroscopy are rare, the most common permanent nerve palsy post-operatively is the posterior interosseous nerve (PIN) followed by the ulnar nerve. Because of the surrounding neurovascular structures, familiarity with the normal elbow anatomy and portals will decrease the risk of damage to important structures. The purpose of this paper is to review important steps in performing elbow arthroscopy with an emphasis on avoiding neurovascular injury. With a sound understanding of the important bony anatomic landmarks, sensory nerves, and neurovascular structures, elbow arthroscopy can provide both diagnostic and therapeutic intervention with little morbidity.

Rates of neurovascular injury, compartment syndrome, and early infection in operatively treated civilian ballistic forearm fractures

PurposeThe purpose of this study is to evaluate the incidence of neurovascular injuries, compartment syndrome, early postoperative infection as well as the injury factors predictive of neurovascular injury following ballistic fractures of the radius and ulna. MethodsA retrospective review was performed to identify all ballistic fractures of the radius and ulna in skeletally mature patients over a 5-year period at a single level-1 trauma center. Chart and radiographic review was performed to identify patient and injury demographics, associated neurologic or vascular injuries, and fracture characteristics. Fracture location was measured on computerized imaging software and fractures were grouped into bone(s) segments involved. Proximal, mid-diaphyseal, and distal locations were used for statistical analysis. ResultsFifty-six extremities in fifty-five patients were identified (mean age 32 years; male to female ratio 9:1). Overall incidence of neurologic injury was 50%, arterial injury 32%, and compartment syndrome 7.1%. Presence of a proximal third forearm fracture was associated with an increased risk for neurologic injury (p < 0.01), with an odds ratio of 5.7 (95% confidence interval, 1.7–18.4). Furthermore, all high velocity/energy ballistic injuries had associated neurologic injuries (p = 0.02). ConclusionBallistic forearm fractures result in high rates of neurovascular injury. Fractures caused by high velocity/energy firearms have extremely high rates of neurologic injury when compared with low velocity ballistic injuries. Ballistic fractures involving the proximal third of the radius or ulna are five times more likely to be associated with neurologic injury after a ballistic injury and should be assessed carefully on initial evaluation.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P92. Does UIV affect rate of pjk in adult deformity surgery fused to the pelvis?

BACKGROUND CONTEXT The rate of proximal junctional kyphosis (PJK) is high in surgery for adult spinal deformity (ASD), especially when the fusions extend to the sacrum and pelvis. Determining the appropriate upper instrumented vertebra (UIV) can sometimes be difficult. Establishing whether rates of PJK are higher in patients with high thoracic vs lower thoracic UIV, may influence the choice of UIV in ASD. PURPOSE To assess the prevalence of PJK in ASD comparing high thoracic and low thoracic UIV in patients fused distally to the pelvis. A secondary question was to determine if rates of neurologic injury secondary to PJK vary according to high versus low thoracic spine UIV. STUDY DESIGN/SETTING Retrospective Cohort. PATIENT SAMPLE A total of 106 cases underwent surgical correction for adult spinal deformity. OUTCOME MEASURES (1) Rate of PJK (2) Rate of neurologic injury. METHODS A total of 143 consecutive patients who underwent surgical correction for ASD between 2007 and 2016 with thoracic to pelvis fusions were assessed. Twenty-eight patients were excluded as their imaging was unavailable due to institutional reasons. A further 8 were excluded due to the EMR containing only partial data. A total of 106 cases were examined (average age 61.0, 80% female). Patients were grouped into high thoracic (HT) UIV (T1–T6) or low thoracic (LT) UIV (T9–T12). PJK was defined as UIV or UIV+1 fracture, kyphosis >10°, or presence of a junctional disc herniation requiring surgery. Presence of PJK was determined by examining 3-foot radiographs at 1 year post-operatively. RESULTS There were 61(57.5%) patients in the HT group and 45(42.4%) in the LT group. PJK occurred in 38 patients (62.5%) in the HT group compared to 12 patients (26.7%) in the LT group (P=0.0004). Proximal junctional kyphosis associated with acute neurologic injury of ASIA A, B or C occurred in two patients in the HT group and 1 patient in the LT group. CONCLUSIONS One-year postoperative PJK prevalence in adult spinal deformity following thoracic to pelvis fusions was higher when the UIV was in the high thoracic spine compared to the lower thoracic region. PJK with associated major neurological deficits was similar in both groups.