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CASE: A healthy 15-year-old male competitive hockey player presented with acute-on-chronic lower back pain was found to have a bilateral pars defect. After conservative treatment, subsequent computed tomography imaging demonstrated partial healing of the right-sided facet fracture but persistent left-sided pars fracture. A novel technique was performed, using robotic navigation to assist in laminar screw placement and to determine the optimal trajectory for subsequent microscopic surgery and bone grafting. CONCLUSION: Robotic navigation can be safely used to not only guide precise laminar screw placement for fixation and direct repair but also to provide guidance for microscopic tubular bone grafting of the pars defect.

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BACKGROUND CONTEXT: Facet joint violation by pedicle screws may lead to adjacent-segment disease and postoperative pain. Previous studies have reported the incidence of rostral facet joint violation using various pedicle screw insertion techniques. However, the incidence of facet joint violations with robotic guidance has not been determined. PURPOSE: To investigate and compare the incidence of rostral facet joint violation by pedicle screws under robotic guidance and computerized tomography (CT) navigation guidance. STUDY DESIGN/SETTING: Retrospective matched cohort. PATIENT SAMPLE: All patients who underwent robotic-assisted lumbar fusion at a major spine center up until 2023 were retrospectively identified and matched 1:3 to patients undergoing CT navigation guidance based by on age, sex, rostral vertebral level, and length of construct. Inclusion criteria consisted of age greater than 18 years, bilateral pedicle screw fixation, and presence of a postoperative CT scan of the lumbar spine or abdomen/pelvis at any point in the post-operative period. OUTCOME MEASURES: Rostral facet joint violations. METHODS: Descriptive statistics were used to compare cohorts: frequencies, chi-squared analysis for categorical variables, and t-test for continuous variables. RESULTS: A total of 408 rostral pedicle screws were implanted in 204 patients (Robot: 102; Navigation: 306). Overall, 13 (12.3%) rostral facet joint violations were observed in the robot cohort and 75 (24.5%) in the navigation cohort (p=.01). Specifically, fewer robotic violations were observed at the L2 (3.5% vs. 32.1%, p=.003) and L3 levels (3.9% vs. 18.1%, p=.08) compared to navigation. No difference was observed at L4 and L5. Bilateral violations are significantly reduced with robotic approaches (5.3% vs. 14.4%, p=.03). Lastly, more facet joint violations were observed during open approaches (robot: 18.8%, navigation: 27.3%) than percutaneous approaches (robot: 11.6%, navigation: 7.1%) in both groups (p<.001). The rate of L4 facet violations was 18.8% in the robotic cohort and 27.3% in the navigation cohort. The rate of L5 facet violations was 31.3% in the robotic cohort and 29.2% in the navigation cohort. CONCLUSIONS: Use of robotic assistance in lumbar pedicle screws significantly reduced the rate of rostral facet joint violations compared to navigation guidance at L2 and L3 levels, but not at L4 and L5, with facet violations approaching nearly one-third of the patients at L5 screws. Rostral facet violations can play a significant role in adjacent segment degeneration and disease. Technical factors and trajectory issues likely play a role and addressing these components should minimize unintended facet violation and proximal adding on.

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The thoracolumbar junction is a complex and challenging anatomical region due to its heterogeneous array of planes and structures.1 Navigating this region during a lateral approach to the spine is a challenge that requires a thorough understanding of the anatomy. We present a case of a 54-year-old woman with a 7-year history of breast cancer who presented with low back pain after running a marathon. To date, the patient had deferred medical management. Imaging revealed Stage IV differentiated invasive ductal carcinoma with extensive bony metastatic disease in multiple areas of the spine. The patient underwent a right-sided minimally invasive retrodiaphragmatic approach to the thoracolumbar junction for L1 corpectomy, placement of an expandable cage, and posterior percutaneous pedicle screw segmental fixation from T11 to L3 with robotic guidance. Patient consent was obtained for the following procedure, and IRB approval was not required for publication of this single patient case report.

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STUDY DESIGN: Retrospective Matched Cohort. OBJECTIVE: Despite known consequences to the facet joints following lumbar total disc replacement (TDR), there is limited data on facet injection usage for persistent postoperative pain. This study uses real-world data to compare the usage of therapeutic lumbar facet injections as a measure of symptomatic facet arthrosis following single-level, stand-alone TDR vs anterolateral lumbar interbody fusion (ALIF/LLIF). METHODS: The PearlDiver database was queried for patients (2010-2021) with lumbar degenerative disc disease who received either a single-level, stand-alone TDR or ALIF/LLIF. All patients were followed for ≥2 years and excluded if they had a history of facet injections or spinal trauma, fracture, infection, or neoplasm. The two cohorts were matched 1:1 based on age, sex, insurance, year of operation, and medical comorbidities. The primary outcome was the use of therapeutic lumbar facet injections at 1-, 2-, and 5-year follow-up. Secondary outcomes included subsequent lumbar surgeries and surgical complications. RESULTS: After 1:1 matching, each cohort had 1203 patients. Lumbar facet injections occurred significantly more frequently in the TDR group at 1-year (6.07% vs 1.66%, P < .0001), 2-year (8.40% vs 3.74%%, P < .0001), and 5-year (11.47% vs 6.40%, P < .0001) follow-up. 5-year injection-free probability curves demonstrated an 87.1% injection-free rate for TDR vs 92.9% for ALIF/LLIF. There was no clinical difference in the incidence of subsequent lumbar surgeries or complications. CONCLUSION: Compared with ALIF/LLIF, patients who underwent TDR received significantly more facet injections, suggesting a greater progression of symptomatic facet arthrosis. TDR was not protective against reoperations compared to ALIF/LLIF.

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BACKGROUND: It is unclear how pediatric orthopedic surgeons are geographically distributed relative to their patients. The purpose of this study was to evaluate the geographic distribution of pediatric orthopedic surgeons in the United States. MATERIALS AND METHODS: County-level data of actively practicing pediatric orthopedic surgeons were identified by matching several registries and membership logs. Data were used to calculate the distance between counties and nearest surgeon. Counties were categorized as "surgeon clusters" or "surgeon deserts" if the distance to the nearest surgeon was less than or greater than the national average and the average of all neighboring counties, respectively. Cohorts were then compared for differences in population characteristics using data obtained from the 2020 American Community Survey. RESULTS: A total of 1197 unique pediatric orthopedic surgeons were identified. The mean distance to the nearest pediatric orthopedic surgeon for a patient residing in a surgeon desert or a surgeon cluster was 141.9±53.8 miles and 30.9±16.0 miles, respectively. Surgeon deserts were found to have lower median household incomes (P<.001) and greater rates of children without health insurance (P<.001). Multivariate analyses showed that higher Rural-Urban Continuum codes (P<.001), Area Deprivation Index scores (P<.001), and percentage of patients without health insurance (P<.001) all independently required significantly greater travel distances to see a pediatric orthopedic surgeon. CONCLUSION: Pediatric orthopedic surgeons are not equally distributed in the United States, and many counties are not optimally served. Additional studies are needed to identify the relationship between travel distances and patient outcomes and how geographic inequalities can be minimized. [Orthopedics. 2024;47(4):e204-e210.].

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PURPOSE: To characterize the frequency of incidental dural tears in pediatric spine surgery, their treatment, complications, and results of long-term follow-up. METHODS: A retrospective review of all pediatric patients who underwent a posterior spinal fusion (PSF) between 2004-2019 at a tertiary children's hospital was conducted. Electronic medical records were reviewed for patient demographics, intra-operative data, presence of an incidental dural tear, repair method, and patient outcomes. RESULTS: 3043 PSFs were reviewed, with 99 dural tears identified in 94 patients (3.3% overall incidence). Mean follow-up was 35.7 months (range 0.1-142.5). When the cause of the dural tear was specified, 69% occurred during exposure, 5% during pedicle screw placement, 4% during osteotomy, 2% during removal of implants, and 2% during intra-thecal injection of morphine. The rate of dural tears during primary PSF was significantly lower than during revision PSF procedures (2.6% vs. 6.2%, p < 0.05). 86.9% of dural tears were repaired and/or sealed intraoperatively, while 13.1% had spontaneous resolution. Postoperative headaches developed in 13.1% of patients and resolved at a mean of 7.6 days. There was no difference in the incidence of headaches in patients that were ordered bedrest vs. no bedrest (p > 0.99). Postoperative infections occurred in 9.5% of patients and 24.1% patients were identified to have undergone a revision surgery. CONCLUSIONS: Incidence of intra-operative dural tears in pediatric spine surgery is 3.3%. Although complications associated with the dural tear occur, most resolve over time and there were no long-term sequelae in patients with 2 years of follow up. LEVEL OF EVIDENCE: Level IV.

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BACKGROUND: The aging population has contributed to a rising incidence of acetabular fractures in older patients, yet current evidence guiding surgical treatment is limited by small sample sizes. This study used a nationwide database to investigate outcomes in older patients undergoing open reduction and internal fixation (ORIF) versus acute total hip arthroplasty (THA). METHODS: The PearlDiver database was queried for patients aged 60 years and older with an acute acetabular fracture who underwent ORIF or acute THA (2010 to 2021). ORIF patients were matched 1:1 to THA patients based on age, sex, US region, insurance plan, and Charlson Comorbidity Index score. Patients with less than 2 years of follow-up were excluded. The primary outcome was revision surgery. RESULTS: Of 120,032 patients with an acetabular fracture, 3,768 (3.1%) underwent surgical treatment: 1,482 (39.3%) THA and 2,286 (60.7%) ORIF. Mean age was 71.0 ± 6.51 years. Mean follow-up duration was 5.2 ± 2.1 years. THA patients were slightly older (72.4 versus 70.2 years), had higher Charlson Comorbidity Index scores (3.3 versus 2.7), and had a higher percentage of female patients (62.5% versus 32.2%). After matching, 962 ORIF and 962 THA patients were included. ORIF patients had longer LOS (10.7 versus 8.1 days). ORIF patients were less likely to experience joint infections and periprosthetic fractures, but more likely to experience transfusions. The overall revision surgery rate within 10 years was 14.8% in the ORIF cohort and 6.2% in the THA cohort. In the ORIF cohort, 13.5% of patients had a delayed conversion to THA. CONCLUSIONS: In this large national database, acute with or without internal fixation for geriatric acetabular fractures was associated with lower rates of revision surgery within 10 years when compared with a matched cohort undergoing ORIF. ORIF was associated with increased LOS, increased transfusion risk, and lower risk of joint infection and periprosthetic fracture. LEVEL OF EVIDENCE: III.

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STUDY DESIGN: Retrospective Cohort. OBJECTIVES: Most data regarding cervical disc arthroplasty (CDA) outcomes are from highly controlled clinical trials with strict inclusion/exclusion criteria. This study aimed to identify risk factors for CDA reoperation, in "real world" clinical practice using a national insurance claims database. METHODS: The PearlDiver database was queried for patients (2010-2020) who underwent a subsequent cervical procedure following a single-level CDA. Patients with less than 2 years follow-up were excluded. Primary outcome was to evaluate risk factors for reoperation. Secondary outcome was to evaluate the types of reoperations. Risk factors were compared using descriptive statistics. Multivariate regression analyses were used to ascertain the association among risk factors and reoperation. RESULTS: Of 14,202 patients who met inclusion criteria, 916 (6.5%) underwent reoperation. Patients undergoing reoperation were slightly older with higher Elixhauser Comorbidity Index (ECI) scores, however both were not risk factors for reoperation. Patients with diagnoses such as smoking, myelopathy, inflammatory disorders, spinal deformity, trauma, or a history of prior cervical surgery were at greater risk for reoperation. No association was found between the year of index surgery and reoperation risk. The most common reoperation procedure was cervical fusion. CONCLUSIONS: As billed for in the United States since 2010, CDA was associated with a 6.5% reoperation rate over a mean follow-up time of 5.3 years. Smoking, myelopathy, inflammatory disorders, spinal deformity, and a history of prior cervical surgery or trauma are risk factors for reoperation following CDA. Though patients who underwent a reoperation were older, age was not found to be an independent risk factor for a subsequent procedure.

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STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: This study compares reoperation rates and complications following single-level ALIF/LLIF and TLIF/PLIF. SUMMARY OF BACKGROUND DATA: Anterior lumbar interbody fusion (ALIF), lateral lumbar interbody fusion (LLIF), transforaminal lumbar interbody fusion (TLIF), and posterior lumbar interbody fusion (PLIF) are widely used for degenerative disc disease. Lumbar interbody fusions have high rates of reoperation primarily related to adjacent segment pathology and pseudarthrosis. METHODS: The PearlDiver database was queried for patients (2010-2021) who had single-level ALIF/LLIF or TLIF/PLIF with same-day, single-level posterior instrumentation. ALIF/LLIF were combined and similarly, TLIF/PLIF were combined, given how these operations are indistinguishable with Current Procedural Terminology (CPT) coding. All patients were followed for ≥2 years and excluded if they had spinal traumas, fractures, infections, or neoplasms prior to surgery. The two cohorts, ALIF/LLIF and TLIF/PLIF, were matched 1:1 based on age, sex, Elixhauser-Comorbidity Index (ECI), smoking status, and diabetes. The primary outcome was the incidence of all-cause subsequent lumbar operations. Secondary outcomes included 90-day surgical complications. RESULTS: After 1:1 matching, each cohort contained 14,070 patients. All-cause subsequent lumbar operations were nearly identical at 5-year follow-up (9.4% ALIF/LLIF vs. 9.5% TLIF/PLIF, P=0.91) (Table 2). Survival analysis using all-cause subsequent lumbar operations as the endpoint showed an equivalent 10-year survival rate of 86.0% (95%CI: 85.2-86.8) (Figure 1). Within 90 days, TLIF/PLIF had more infections (1.3% vs. 1.7%, P=0.007) and dural injuries (0.2% vs. 0.4%, P=0.001). There was no difference in wound dehiscence, hardware complications, or medical complications (Table 3). CONCLUSION: As utilized in real-world clinical practice, single-level anterolateral versus posterior approaches for interbody fusion have no effect on long term reoperation rates.

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Objectives: Geriatric patients who sustain hip fractures and are taking factor Xa inhibitors (Xa-I) experience surgical delay. Our institution developed a pharmacokinetic protocol to formally guide and expedite surgical timing for these patients. The protocol is based on the patient's renal function and timing of last Xa-I dose. For patients with impaired renal function, longer wait times are recommended. The purpose of this study was to determine the effects of this protocol for patients with geriatric hip fracture taking Xa-I. Design: Retrospective cohort study. Setting: Level 1 trauma center. Patients/Participants: A total of 164 patients aged 65 and older who were taking Xa-I before admission and underwent hip fracture surgery; 68 patients in the Standard group (2014-2018) and 96 patients in the Expedited group (2020-2022, after protocol implementation). Intervention: Hip fracture surgery. Main Outcome Measurements: Time to surgery (TTS), transfusion rate, blood loss, 90-day complication rates. Results: The median TTS was significantly shorter in the Expedited group (28.6 hours, interquartile range 21.3 hours) than in the Standard group (44.8 hours, interquartile range 21.1 hours) (P < .001). There were no differences in overall transfusion rates. Multivariable regression analysis demonstrated that time to surgery was not predictive of transfusion rate in all patients (OR 1.00, 95% CI 0.99-1.02, P = .652). There were no differences in blood loss or rates of 90-day complications. Conclusion: Geriatric patients with hip fractures and taking factor Xa inhibitors may warrant earlier surgery without an increased risk of transfusion or bleeding. Level of Evidence: Therapeutic Level III.

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CASE: A healthy 5-year-old boy presented with a gradual onset of headaches and acute global right-sided weakness over 10 days. The work-up revealed unstable os odontoideum leading to multiple posterior circulation infarcts with vertebral artery dissection. He underwent antiplatelet therapy, cervical collar immobilization, and delayed occiput to C2 posterior spinal fusion and instrumentation with iliac crest autograft. At 2-year follow-up, the patient had a solid fusion mass, appropriate cervical alignment, and was without neurologic sequelae. CONCLUSION: This case adds to a sparse body of literature in the management of vertebral artery dissection with vertebrobasilar insufficiency secondary to unstable os odontoideum.

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Introduction: Management of spondylolysis in adolescents is generally successful with conservative management. Uncommonly, surgical fixation is necessary for refractory cases. Direct repair with intralaminar screws is one commonly utilized technique. Recently, less invasive spinal procedures are becoming viable with the enabling of technologies, including robotics. Case description: A 14-year-old baseball player and surfer presented with low back pain, diagnosed by MRI as bony edema and stress fractures of the posterior spinal elements. After 18 months, the pain was unresponsive to rest, physical therapy, and bracing. There was no radicular pain or neurologic symptoms. Computed tomography (CT) revealed bilateral, chronic nonhealing pars defects at L5. He underwent outpatient, robot-assisted percutaneous intralaminar fixation with hydroxyapatite-coated screws through a 2 cm skin incision. Outcome: On postoperative day 1, the patient reported relief of his preoperative pain and he was ambulating without difficulty. At 2 weeks follow-up, the patient was completely pain free and surfing. At 2 months follow-up, low-dose CT demonstrated partial incorporation of the hydroxyapatite-coated screws, and the patient returned to sports. At 6 months follow-up, the patient had no pain and was swinging his baseball bat with full force. Low-dose CT revealed complete healing of the defects with full incorporation of the hydroxyapatite-coated screws. Conclusions: A novel minimally invasive robotic percutaneous approach for direct spondylolysis repair using hydroxyapatite-coated screws is a potential surgical treatment option for non-healing pars defects in adolescent patients.

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PURPOSE: This study aimed to examine the injury and illness characteristics, treatments, and outcomes at elite ultraendurance triathlon events. METHODS: We quantified participant demographics, injury types, treatments, and disposition for medical encounters at 27 Ironman-distance triathlon championships from 1989 to 2019. We then calculated the likelihood of concurrent medical complaints in each encounter. RESULTS: We analyzed 10,533 medical encounters among 49,530 race participants for a cumulative incidence of 221.9/1000 participants (95% confidence interval [CI] = 217.7-226.2). Younger (<35 yr; 259.3/1000, 95% CI = 251.6-267.2) and older athletes (70+ yr; 254.0/1000, 95% CI = 217.8-294.4) presented to the medical tent at higher rates than middle-age adults (36-69 yr; 180.1/1000, 95% CI = 175.4-185.0). Female athletes also presented at higher rates when compared with males (243.9/1000, 95% CI = 234.9-253.2 vs 198.0/1000, 95% CI = 193.4-202.6). The most common complaints were dehydration (438.7/1000, 95% CI = 426.2-451.6) and nausea (400.4/1000, 95% CI = 388.4-412.6). Intravenous fluid was the most common treatment (483/1000; 95% CI = 469.8-496.4). Of the athletes who received medical care, 116.7/1000 (95% CI = 110.1-123.4) did not finish the race, and 17.1/1000 (95% CI = 14.7-19.8) required hospital transport. Athletes rarely presented with an isolated medical condition unless their injury was dermatologic or musculoskeletal in nature. CONCLUSIONS: Ultraendurance triathlon events have high rates of medical encounters among female athletes, as well as both younger and older age categories. Gastrointestinal and exertional-related symptoms are among the most common complaints. Intravenous infusions were the most common treatment after basic medical care. Most athletes entering the medical tent finished the race, and a small percentage were dispatched to the hospital. A more thorough understanding of common medical occurrences, including concurrent presentations and treatments, will allow for improved care and optimal race management.

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