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STUDY DESIGN: Retrospective multicenter study. OBJECTIVES: To investigate surgical outcomes following posterior decompression for cervical ossification of the posterior longitudinal ligament (OPLL) when performed by board-certified spine (BCS) or non-BCS (NBCS) surgeons. METHODS: We included 203 patients with cervical OPLL who were followed for a minimum of 1 year after surgery. Demographic information, medical history, and imaging findings were collected. Clinical outcomes were assessed preoperatively and at the final follow-up using the Japanese Orthopedic Association (JOA) score and the visual analog scale (VAS) for the neck. We compared outcomes between BCS surgeons, who must meet several requirements, including experience in more than 300 spinal surgeries, and NBCS surgeons. RESULTS: BCS surgeons performed 124 out of 203 cases, while NBCS surgeons were primary in 79 cases, with 73.4% were directly supervised by a BCS surgeon. There was no statistically significant difference in surgical duration, estimated blood loss, and perioperative complication rates between the BCS and NBCS groups. Moreover, no statistically significant group differences were observed in each position of the C2-7 angle and cervical range of motion at preoperation and the final follow-up. Preoperative and final follow-up JOA scores, VAS for the neck, and JOA score recovery rate were comparable between the two groups. CONCLUSIONS: Surgical outcomes, including functional recovery, complication rates, and cervical dynamics, were comparable between the BCS and NBCS groups. Consequently, posterior decompression for cervical OPLL is considered safe and effective when conducted by junior surgeons who have undergone training and supervision by experienced spine surgeons.

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STUDY DESIGN: This was a descriptive study through secondary analysis of aggregated data. PURPOSE: This study aimed to describe changes in women's membership in the Japanese Society for Spine Surgery and Related Research (JSSR) for orthopedic surgery and the Neurospinal Society of Japan (NSJ) for neurosurgery over the past decade and make predictions for the future. OVERVIEW OF LITERATURE: Although the ratio of women physicians in the field of spine surgery is known to be low worldwide, there is a lack of detailed surveys in Japan. METHODS: We sent emails to the JSSR and NSJ secretariats to verify membership information (gender and age) from 2013 to 2022. Using ordinary least squares, we projected the years it would take for the JSSR and NSJ to achieve a gender diversity ratio of 30%. RESULTS: In 2013, the percentage of women in JSSR and NSJ was 2.3% and 2.7%, respectively. However, after 2018, the percentage of women in NSJ will be higher than in JSSR, rising to 2.7% in JSSR and 4.7% in NSJ by 2022. It would require 101 years for the NSJ and more than 1,000 years for the JSSR to realize 30% gender diversity. CONCLUSIONS: JSSR and NSJ have low percentages of women. Improving gender diversity is an important issue for both societies, and they may collaborate on finding a good solution. Both the JSSR and NSJ societies need to actively address gender diversity and become more attractively represented in society for the next generation of spine surgeons.

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Background: Cauda equina syndrome (CES) is a consequence of a variety of etiologies. CES is most commonly due to compression of the thecal sac and nerve roots by a massive disc herniation. However, it rarely presents secondary to aortic occlusion. Aortoiliac occlusive disorder is usually associated with chronic claudication, erectile dysfunction, and diminished lower limb pulses. Acute aortic occlusion, however, is associated with serious complications such as spinal cord infarction and ischemia. It is also associated with a high risk of morbidity and mortality. Moreover, it poses a diagnostic challenge and may be overlooked. This report emphasizes the importance of considering vascular etiology as a differential diagnosis for CES. Case Description: This case report describes a unique case of aortic occlusion mimicking CES in a 56-year-old female patient. Conclusion: For patients presenting with cauda equina symptomatology, it is critical to consider vascular etiology, especially for those with cardiovascular risk factors. Spine surgeons and emergency physicians should maintain a high index of suspicion for vascular etiologies and consider appropriate imaging studies to promote early diagnosis and intervention to prevent subsequent neurological and life-threatening consequences.

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INTRODUCTION: in general, spine surgeons seek to minimize soft tissue damage by using less invasive approaches, which causes them to use intraoperative images much more frequently than other surgical specialties; therefore, they are at increased risk of radiation exposure. OBJECTIVE: the aim of this work was to analyse the amount of radiation to which the spine surgeon is exposed in different scenarios. MATERIAL AND METHODS: a prospective study with a descriptive, longitudinal non-randomized data source. We carried out this study in the period from 2015 to 2019, the radiologic protection consisted in lead apron, thyroid shield and leaded glasses, there were 10 badge dosimeters. RESULTS: only 4 dosimeters were included in the study, the other six were excluded. During the study period one surgeon suffered thyroid cancer and other suffered of liposarcoma. In the protected group were two surgeons, in the group of aleatory exposition was one surgeon and in the unprotected group was one surgeon. In the study the dosimeter in the unprotected group received more amount of radiation in all the years, we did an inferential analysis per year related with the number of surgeries without significant correlation, we attribute this result because we didn't classified the type of surgery realized by each surgeon. CONCLUSION: we conclude that the spine surgeon must apply the primary methods of radiological protection and that the unprotected spine surgeon receives more amount of radiation in comparison of the protected ones.

INTRODUCCIÓN: en general, los cirujanos de columna buscan minimizar el daño a tejidos blandos empleando abordajes menos invasivos, lo que ocasiona que utilicen imágenes intraoperatorias de una manera mucho más habitual que el resto de las especialidades quirúrgicas; por lo tanto, están en mayor riesgo de exposición de radiación. OBJETIVO: el propósito del trabajo es analizar la cantidad de radiación a la cual está expuesto el cirujano de columna en diferentes escenarios. MATERIAL Y MÉTODOS: estudio prospectivo con una fuente de datos descriptiva, longitudinal, no aleatorizada. Se llevó a cabo el estudio en el período del año 2015 al 2019; la protección radiológica consistió en chaleco plomado, protector de tiroides y lentes plomados; se usaron 10 dosímetros. RESULTADOS: cuatro dosímetros fueron incluidos en el estudio, los otros seis fueron excluidos. Durante el estudio, un cirujano sufrió de cáncer de tiroides y otro de liposarcoma. En el grupo de protegidos se incluyeron dos cirujanos, en el grupo de protección aleatorizada se incluyó un cirujano y en el grupo sin protección se incluyó un cirujano. El dosímetro del grupo sin protección recibió mayor cantidad de radiación en todos los años, se realizó un análisis inferencial por año relacionado con el número de cirugías no encontrando correlación significativa, atribuimos este resultado a que no clasificamos el tipo de cirugía realizada por cada cirujano. CONCLUSIÓN: el cirujano de columna debe de aplicar los métodos primarios de protección radiológica, ya que los cirujanos de columna sin equipo de protección reciben mayor cantidad de radiación en comparación con los protegidos.

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Resumen: Introducción: en general, los cirujanos de columna buscan minimizar el daño a tejidos blandos empleando abordajes menos invasivos, lo que ocasiona que utilicen imágenes intraoperatorias de una manera mucho más habitual que el resto de las especialidades quirúrgicas; por lo tanto, están en mayor riesgo de exposición de radiación. Objetivo: el propósito del trabajo es analizar la cantidad de radiación a la cual está expuesto el cirujano de columna en diferentes escenarios. Material y métodos: estudio prospectivo con una fuente de datos descriptiva, longitudinal, no aleatorizada. Se llevó a cabo el estudio en el período del año 2015 al 2019; la protección radiológica consistió en chaleco plomado, protector de tiroides y lentes plomados; se usaron 10 dosímetros. Resultados: cuatro dosímetros fueron incluidos en el estudio, los otros seis fueron excluidos. Durante el estudio, un cirujano sufrió de cáncer de tiroides y otro de liposarcoma. En el grupo de protegidos se incluyeron dos cirujanos, en el grupo de protección aleatorizada se incluyó un cirujano y en el grupo sin protección se incluyó un cirujano. El dosímetro del grupo sin protección recibió mayor cantidad de radiación en todos los años, se realizó un análisis inferencial por año relacionado con el número de cirugías no encontrando correlación significativa, atribuimos este resultado a que no clasificamos el tipo de cirugía realizada por cada cirujano. Conclusión: el cirujano de columna debe de aplicar los métodos primarios de protección radiológica, ya que los cirujanos de columna sin equipo de protección reciben mayor cantidad de radiación en comparación con los protegidos.

Abstract: Introduction: in general, spine surgeons seek to minimize soft tissue damage by using less invasive approaches, which causes them to use intraoperative images much more frequently than other surgical specialties; therefore, they are at increased risk of radiation exposure. Objective: the aim of this work was to analyse the amount of radiation to which the spine surgeon is exposed in different scenarios. Material and methods: a prospective study with a descriptive, longitudinal non-randomized data source. We carried out this study in the period from 2015 to 2019, the radiologic protection consisted in lead apron, thyroid shield and leaded glasses, there were 10 badge dosimeters. Results: only 4 dosimeters were included in the study, the other six were excluded. During the study period one surgeon suffered thyroid cancer and other suffered of liposarcoma. In the protected group were two surgeons, in the group of aleatory exposition was one surgeon and in the unprotected group was one surgeon. In the study the dosimeter in the unprotected group received more amount of radiation in all the years, we did an inferential analysis per year related with the number of surgeries without significant correlation, we attribute this result because we didn't classified the type of surgery realized by each surgeon. Conclusion: we conclude that the spine surgeon must apply the primary methods of radiological protection and that the unprotected spine surgeon receives more amount of radiation in comparison of the protected ones.

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OBJECTIVE: The objective of this paper was to determine the interobserver reliability and intraobserver reproducibility of the AO Spine Upper Cervical Injury Classification System based on surgeon experience (< 5 years, 5-10 years, 10-20 years, and > 20 years) and surgical subspecialty (orthopedic spine surgery, neurosurgery, and "other" surgery). METHODS: A total of 11,601 assessments of upper cervical spine injuries were evaluated based on the AO Spine Upper Cervical Injury Classification System. Reliability and reproducibility scores were obtained twice, with a 3-week time interval. Descriptive statistics were utilized to examine the percentage of accurately classified injuries, and Pearson's chi-square or Fisher's exact test was used to screen for potentially relevant differences between study participants. Kappa coefficients (κ) determined the interobserver reliability and intraobserver reproducibility. RESULTS: The intraobserver reproducibility was substantial for surgeon experience level (< 5 years: 0.74 vs 5-10 years: 0.69 vs 10-20 years: 0.69 vs > 20 years: 0.70) and surgical subspecialty (orthopedic spine: 0.71 vs neurosurgery: 0.69 vs other: 0.68). Furthermore, the interobserver reliability was substantial for all surgical experience groups on assessment 1 (< 5 years: 0.67 vs 5-10 years: 0.62 vs 10-20 years: 0.61 vs > 20 years: 0.62), and only surgeons with > 20 years of experience did not have substantial reliability on assessment 2 (< 5 years: 0.62 vs 5-10 years: 0.61 vs 10-20 years: 0.61 vs > 20 years: 0.59). Orthopedic spine surgeons and neurosurgeons had substantial intraobserver reproducibility on both assessment 1 (0.64 vs 0.63) and assessment 2 (0.62 vs 0.63), while other surgeons had moderate reliability on assessment 1 (0.43) and fair reliability on assessment 2 (0.36). CONCLUSIONS: The international reliability and reproducibility scores for the AO Spine Upper Cervical Injury Classification System demonstrated substantial intraobserver reproducibility and interobserver reliability regardless of surgical experience and spine subspecialty. These results support the global application of this classification system.

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INTRODUCTION: Orthopedic surgeons are exposed to ionizing radiation daily. With the increase in the number of minimally invasive surgery performed under X-ray fluoroscopy, radiation exposure to unprotected fingers will increase. Although the effect of high dose radiation exposure is known, the long-term effect of exposure to low doses is unclear. This study aims to investigate damage to the nail and skin on the thumbs of spine surgeons via occupational ionizing radiation exposure. METHODS: Forty male spine surgeons (group S) and 40 males of the same age group who were not exposed to radiation (controls; group C) were included. Using a scoring system, we evaluated the damage to the fingernail and skin of the bilateral thumb. Scoring was based on fingernail pigmentation (melanonychia), fingernail crack, and periungual dermatitis status. We investigated the number of examinations and operations under radiation exposure in the last 3 months. RESULTS: Group S had 17.83 (3-28) years of surgeon experience. In group S, the dominant side scored significantly higher than the non-dominant side; however, there was no dominant vs. non-dominant difference in group C. Only the dominant side had a significantly higher score in group S than in group C. In group S, surgeon experience and the score of the dominant side were significantly correlated; however, for the non-dominant side of group S and both thumbs of group C, no correlation was observed. The kappa coefficients for fingernail pigmentation, fingernail crack, and periungual dermatitis status were 0.458, 0.248, and 0.612, respectively. The average number of examinations and operations under radiation exposure was 11.89 ± 9.04 (0-30) and 26.34 ± 14.67 (1-63), respectively. CONCLUSIONS: The dominant side in group S had a significantly higher score than the non-dominant side in group S and the dominant side in group C, suggesting the possibility of radiation damage to the dominant side in group S.

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BACKGROUND/AIM: It is important to perform early intervention on bone metastases using multidisciplinary approaches, however it is difficult to hold frequent meetings between patients and clinicians. We aimed to evaluate the usefulness of a specialized outpatient clinic on bone metastasis, instead of the multidisciplinary approach currently in practice. PATIENTS AND METHODS: We included 31 patients with vertebral metastases of various carcinomas, undergoing surgical treatment by spine surgeons. We divided the patients into two groups before and after their visit to the specialized outpatient clinic (pre and post groups), and compared their clinical characteristics. RESULTS: The post group demonstrated a longer period from consulting the spine surgeon to the surgery than the pre group (p=0.0129). A multivariate logistic regression analysis revealed that the period from spine surgeon consultation to surgery was significantly associated with a specialized outpatient clinic visit (p=0.0460). CONCLUSION: Specialized outpatient clinics on bone metastasis could possibly reduce the burden on spinal surgeons.

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BACKGROUND: There is a paucity of information regarding treatment strategies and variables affecting outcomes of revision lumbar fusions. OBJECTIVE: To evaluate the influence of primary vs different surgeon on functional outcomes of revisions. METHODS: All elective lumbar fusion revisions, March 2018 to August 2019, were retrospectively categorized as performed by the same or different surgeon who performed the primary surgery. Oswestry Disability Index (ODI) and clinical variables were collected. Multiple logistic regression identified multivariable-adjusted odds ratio (OR) of independent variables analyzed. RESULTS: Of the 130 cases, 117 (90%) had complete data. There was a slight difference in age in the same (median: 59; interquartile range [IQR], 54-66) and different surgeon (median: 67; IQR, 56-72) groups (P = .02); all other demographic variables were not significantly different (P > .05). Revision surgery with a different surgeon had an ODI improvement (median: 8; IQR, 2-14) greater than revisions performed by the same surgeon (median: 1.5; IQR, -3 to 10) (P < .01). Revisions who achieved minimum clinically important difference (MCID) performed by different surgeon (59.7%) were also significantly greater than the ones performed by the same surgeon (40%) (P = .042). Multivariate analysis demonstrated that a different surgeon revising (OR, 2.37; [CI]: 1.007-5.575, P = .04) was an independent predictor of MCID achievement, each additional 2 years beyond the last surgery conferred a 2.38 ([CI]: 1.36-4.14, P < .01) times greater odds of MCID achievement, and the anterior lumbar interbody fusion approach decreased the chance of achieving MCID (OR, 0.19; [CI]: 0.04-0.861, P = .03). CONCLUSION: All revision lumbar spinal fusion approaches may not achieve the same outcomes. This analysis suggests that revision surgeries may have better outcomes when performed by a different surgeon.

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An intraoperative functional spinal cord monitoring system is a technology used by spine and spinal cord surgeons to perform a safe surgery and to gain further surgical proficiency. However, no existing clinical neurophysiological method used in the operating room can monitor all complex spinal cord functions. Therefore, by observing the activities of certain neural action potentials transferred via limited neural tissues, surgeons need to deductively estimate the function of the whole spinal cord. Thus, as the number of spinal cord functions that need to be observed increases, spinal cord monitoring can be more reliable. However, in some situations, critical decision-making is affected by the limited capability of these methods. Nevertheless, good teamwork enables sharing of seamless information within the team composed of a surgeon, anesthesiologist, monitoring technician and nurses greatly contributes to making quick and accurate decisions. The surgeon, who is the person in charge of the team, should communicate with multidisciplinary team members using common technical terms. For this reason, spine and spinal cord surgeons must have appropriate knowledge of the methods currently used, especially of their utility and limitations. To date, at least six electrophysiological methods are available for clinical utilization: three are used to monitor sensory-related tracts, and three are used to monitor motor-related spinal cord functions. If surgeons perform electrode setting, utilizing their expertise, then the range of available methods is broadened, and more meticulous intraoperative functional spinal cord monitoring can be carried out. Furthermore, if the team members share information effectively by utilizing a clinically feasible judicious checklist or tools, then spinal cord monitoring will be more reliable.

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BACKGROUND: This study evaluates the accuracy, biomechanical profile, and learning curve of the transverse process trajectory technique (TPT) compared to the straightforward (SF) and in-out-in (IOI) techniques. SF and IOI have been used for fixation in the thoracic spine. Although widely used, there are associated learning curves and symptomatic pedicular breaches. We have found the transverse process to be a reproducible pathway into the pedicle. METHODS: Three surgeons with varying experience (experienced [E] with 20 years in practice, surgeon [S] with less than 10 years in practice, and senior resident trainee [T] with no experience with TPT) operated on 8 cadavers. In phase 1, each surgeon instrumented 2 cadavers, alternating between TPT and SF from T1 to T12 (n = 48 total levels). In phase 2, the E and T surgeons instrumented 1 cadaver each, alternating between TPT and IOI. Computed tomography scans were analyzed for accuracy of screw placement, defined as the percentage of placements without critical breaches. Axial pullout and derotational force testing were performed. Statistical analyses include paired t test and analysis of variance with Tukey correction. RESULTS: Overall accuracy of screw placement was comparable between techniques (TPT: 92.7%; SF: 97.2%; IOI: 95.8%; P = .4151). Accuracy by technique did not differ for each individual surgeon (E: P = .7733; S: P = .3475; T: P = .4191) or by experience level by technique (TPT: P = .1127; FH: P = .5979; IOI: P = .5935). Pullout strength was comparable between TPT and SF (571 vs 442 N, P = .3164) but was greater for TPT versus IOI (454 vs 215 N, P = .0156). There was a trend toward improved derotational force for TPT versus SF (1.06 vs 0.93 Nm/degrees, P = .0728) but not for TPT versus IOI (1.36 vs 1.16 Nm/degrees, P = .74). Screw placement time was shortest for E and longest for T for TPT and SF and not different for IOI (TPT: P = .0349; SF: P < .0001; IOI: P = .1787) but did not vary by technique. CONCLUSIONS: We describe the TPT, which uses the transverse process as a corridor through the pedicle. TPT is an accurate method of thoracic pedicle screw placement with potential biomechanical advantages and with acceptable learning curve characteristics. CLINICAL RELEVANCE: This study provides the surgeon with a new trajectory for pedicle screw placement that can be used in clinical practice.

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BACKGROUND: Academic productivity plays a growing role in professional advancement in academic medicine. This study aimed to assess academic productivity among spine surgeons by investigating differences in h indices between neurological and orthopedic spine surgeons. METHODS: The American Association of Neurological Surgeons (AANS) Neurosurgical Residency Training Program Directory provided names of U.S. and Canadian academic neurological surgeons. The National Institutes of Health (NIH) Research Portfolio Online Reporting Tools database was consulted for NIH funding statuses of the surgeons. Scopus yielded the h indices. Orthopedic spine surgeons were identified at the same institutions as the neurological spine surgeons, and NIH funding statuses and h indices were identified from the same databases. Differences between the disciplines and across the categories of NIH funding receipt, having a Ph.D., and academic rank were analyzed. RESULTS: Inclusion criteria were met by 215 neurological spine surgeons and 513 orthopedic spine surgeons. Neurological spine surgeons had a mean h index of 21.16, and orthopedic spine surgeons had a mean h index of 14.08 (P < 0.0001). Neurological surgeons with NIH funding had higher (P < 0.0001) h indices (34.15) than surgeons without funding (19.29). Likewise, orthopedic surgeons with NIH funding had higher (P < 0.001) h indices (42.83) than surgeons without funding (13.39). Analysis of variance showed that department chairmen and professors had higher h indices than associate or assistant professors among neurological (P < 0.01) and orthopedic (P < 0.001) surgeons. CONCLUSIONS: These results demonstrate the importance of the h index in measuring academic productivity among neurological and orthopedic spine surgeons.

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INTRODUCTION: During the recent decade, many outbreaks of infectious diseases have been reported at increasing scales and frequency. The novel COVID-19 is the most recent lethal virus and has been declared to be a pandemic disease on March 11th, 2020. It has spread from China to most of the countries around the world causing a great burden on individuals and communities. The socioeconomic and professional profiles have been affected seriously by this pandemic. The aim of this study was to assess the short-term effects of COVID-19 on the socioeconomic profile of spinal surgeons in Egypt. METHODS: We conducted a cross-sectional online survey study to address the effect of COVID-19 global pandemic on spine surgeons in Egypt, discussing the short-term socioeconomic effect of COVID-19 global pandemic on the professional and social profiles of the Egyptian spine surgeons. A SurveyMonkey® questionnaire was sent to 190 spine surgeons registered in the Egyptian spine association database. RESULTS: Ninety male surgeons responded to our four-day survey. The responders included the following: 4 residents, 16 fellows, and 70 consultants working in different Egyptian hospitals. The partial country lockdown was associated with drop in monthly income and in number of both elective and emergency operations. Most surgeons either stopped surgery or limited the number of either elective or emergency surgeries as well as outpatient clinics. Most of them were not in the COVID-19 team or did not receive any training, working under immense physical and psychological stress of being exposed to transmission of infection. DISCUSSION: COVID-19 global pandemic negatively affected spine surgeons in Egypt socioeconomically. The Health Authority and the community have to work jointly to help the health care professionals in overcoming this crisis.

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BACKGROUND: In the next decade, health care reimbursement will be more aligned to patient clinical outcomes. These outcomes are influenced by the patient's perceived opinion of his or her care. An evaluation into the role of surgeon demographics, social media (SM) accessibility, and office wait times was conducted to identify correlations with these among 3 online review platforms. METHODS: A total of 206 (148 orthopedic, 58 neurosurgery trained) spine surgeons were included. Spine surgeon ratings and demographics data from 3 physician rating websites (Healthgrades.com [HG], Vitals.com, Google.com [G]) were collected in November 2019. Using the first 10 search results from G we then identified if the surgeons had publicly accessible Facebook, Twitter, or Instagram (IG) accounts. RESULTS: The mean age of the cohort was 54.3 years (±9.40 years), and 28.2% had one form of publicly accessible SM. Having any SM was significantly correlated with higher scores on HG and G. An IG account was associated with significantly higher scores on all 3 platforms, and having a Facebook account correlated with significantly higher scores on HG in multivariate analysis. An office wait time between 16 and 30 minutes and >30 minutes was associated with worse scores on all 3 platforms (all P < 0.05). An academic practice was associated with higher scores on all 3 platforms (P < 0.05). CONCLUSIONS: A shorter office wait time and an academic setting practice are associated with higher patient satisfaction scores on all 3 physician review websites. Accessible SM accounts are also associated with higher ratings on physician review websites, particularly IG.

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BACKGROUND: Traditionally trained spine surgeons may want to transition from open spinal surgeries to endoscopic decompressions. The aspiring endoscopic spine surgeon may have to overcome multiple hurdles to master a learning curve without readily available training. Replacing traditional time-proven open spinal surgeries with endoscopic decompression may put the surgeons' reputation at risk and have an additional negative impact on his or her practice due to reduced revenue. The authors report on the utility of the mentor- and proctorship concepts to facilitate the transition from traditional open to endoscopic outpatient spine surgeries. METHODS: The study population (learning curve groups) was provided by two traditionally trained "apprentice" surgeons who have been in practice for 12 and 28 years, respectively. They trained with the remaining two authors under mentorship and proctorship arrangements. A VAS and Macnab outcomes analysis was performed by one surgeon laminectomy versus endoscopy in relationship to the case log representative of the initial learning curve. The second surgeon performed a postoperative narcotic utilization analysis as a representative way of favorable clinical outcomes in relation to his increasing case log with spinal endoscopy. RESULTS: The learning curve study by the first author (NA Ransom-under the proctorship program) consisted of 40 patients with 20 patients each divided into the traditional laminectomy control group and 20 patients in the endoscopic group. There were 22 females and 18 males with an average age of 57.38 years and a mean follow-up of 38.58 months. The preoperative VAS for patients in both groups was 7.95 compared to the postoperative VAS at final follow-up of 4.01 with a statistically significant postoperative VAS reduction (P<0.001) but without any significant difference between open laminectomy control- and endoscopic decompression groups. The endoscopic learning curve group outcomes improved significantly after 15 cases (P<0.048). The second author (S Gollogly-under mentorship program) performed a similar review of his surgical cases log and noted a significant reduction of postoperative narcotic utilization as a result of improved outcomes after an initial learning curve of 15 cases. Clinical outcomes for both authors showed improved Macnab outcomes in the majority of patients (NA Ransom =65%; S Gollogly =57%) with a slightly higher success rate in the laminectomy group (70%) versus the endoscopy group (65%) at a statistical significant level (P=0.036). CONCLUSIONS: The mentorship and proctorship approach is useful in helping traditionally trained spine surgeons to integrate spinal endoscopy into their well-established spine practices. Under the close guidance of an endoscopic master spine surgeon, the endoscopic learning curve may be comprehended by the experienced traditionally trained spine surgeon in approximately 15 lumbar decompression cases. During this initial 15-case learning curve, clinical outcomes with endoscopy may be slightly inferior to open laminectomy but may ultimately improve to equivalent levels.

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STUDY DESIGN: Observational study. PURPOSE: The purpose of this study is to analyze the surgeon's neck postures while performing lumbar spinal surgeries. OVERVIEW OF LITERATURE: Lumbar spinal surgeries are on rising trend, and with increase in number of procedures, the average time spent by a spine surgeon performing surgical procedures is also increasing. The effect of operating posture on the surgeon's neck is largely unknown. From the studies conducted on usage of smartphones, abnormal neck postures, especially the forward head posture (FHP), were found to adversely affect the cervical spine of individuals. The present study analyzes the neck position of spine surgeons during lumbar spine surgeries. METHODOLOGY: Sixty video recordings (25 open transforaminal lumbar interbody fusions [TLIFs] and 35 lumbar decompression [LD] procedures - 15 with headlight and 20 with operating microscope) of surgeries performed by three spine surgeons of different heights were analyzed. Running videos of the surgeries were recorded concentrating on the surgeons with reflective markers taped to their surface landmarks corresponding to C7 spinous process, tragus of the ear, and outer canthus of the eye. Video recordings were standardized by a fixed video recorder in the same operating theater. Snapshots from the video were obtained whenever the surgeon changes the position. Head flexion angle (HFA), neck flexion angle (NFA), and cervical angle (CA) were measured and analyzed. RESULTS: During TLIF, HFA and NFA were significantly higher during the phases of decompression and fusion (P < 0.05). The average CA of all surgeons was lower, thereby adversely affecting the cervical spine (20.15° ± 5.05°). During LD, CA showed significant difference between usage of microscope and headlight (P < 0.001). CONCLUSION: Surgeon's FHP is frequently caused by a compromise between the need to perform surgery with hands, without elevating the arms, and simultaneous control of gaze at surgical field. The usage of microscope was found to reduce the stress on neck while performing surgery.

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STUDY DESIGN: Retrospective multicenter study. OBJECTIVES: To evaluate the outcomes of posterior cervical decompression for cervical spondylotic myelopathy (CSM) when performed by board-certified spine (BCS) or non-BCS (NBCS) surgeons. METHODS: We reviewed outcomes for 675 patients who underwent surgery for CSM, were followed at least 1 year after surgery, and were assessed preoperatively and at final follow-up by Japanese Orthopaedic Association (JOA) scores and by the visual analog scale (VAS) for the neck. Cervical alignment was assessed on radiographs by C2-C7 angles, and range of motion (ROM) by extension minus flexion C2-C7 angles. We compared outcomes for BCS surgeons, who must meet several requirements, including experience in more than 300 spinal surgeries, and for NBCS surgeons. RESULTS: BCS surgeons performed 432 of 675 laminoplasties. NBCS surgeons were primary in 243 surgeries, of which 187 were directly supervised by a BCS surgeon. BCS surgeons required significantly less time in surgery (98.0 ± 39.5 vs 108.1 ± 49.7 min; P < .01). BCS and NBCS surgeons had comparable perioperative complications rates, and preoperative-to-postoperative changes in JOA scores (2.9 ± 2.1 vs 3.1 ± 2.3; P = .40) and VAS (-1.5 ± 2.9 vs -1.4 ± 2.5; P = .96). Lordotic cervical alignment and ROM were maintained after operations by both groups. CONCLUSIONS: Surgical outcomes such as functional recovery, complication rates, and cervical dynamics were comparable between the BCS and NBCS groups. Thus, posterior cervical decompression for CSM is safe and effective when performed by junior surgeons who have been trained and supervised by experienced spine surgeons.

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BACKGROUND: Online physician rating websites are increasingly used by patients to evaluate their doctors. The purpose of this investigation was to evaluate factors associated with better spine surgeon ratings. METHODS: Orthopedic spine surgeons were randomly selected from the North American Spine Society directory utilizing a random number generator. Surgeon profiles on three physician rating websites, namely, www.HealthGrades.com, www.Vitals.com, and www.RateMDs.com, were analyzed to gather qualitative and quantitative data on patients' perceptions of the surgeons. Independent variables from the websites were analyzed in relation to overall physician or patient satisfaction rating. Comments were coded by subject into following three categories: professional competence, bedside manner, and practice characteristics. RESULTS: A total of 250 surgeons were evaluated, and 92% (n=230) of these doctors had at least one rating among the three websites. The surgeons with a higher average rating had significantly better trust (p<.01), scheduling (p<.01), staff (p<.01), helpfulness (p<.01), and punctuality (p<.01) scores but significantly less experience (p<.05). A linear regression model for the average rating of each surgeon (R2 value=0.754) yielded only following three significant variables: trustworthiness (p<.01), experience match (p<.05), and the average number of negative comments on surgeon's professional competence (p<.05). Trustworthiness (ß=0.749) was the strongest predictor variable of physician rating, followed by the number of negative professional competence comments (ß=-0.132) and experience match (ß=-0.112). CONCLUSIONS: This investigation assessed spine surgeon online patient ratings and categorized factors that patients associate with quality care. Trustworthiness was the most significant predictor of positive ratings, whereas ease of scheduling, quality of staff, helpfulness, and punctuality were also associated with higher patient ratings. Understanding what patients value may help optimize care of spine surgery patients.

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OBJECTIVEThe purpose of this study was to assess the impact of certain demographics, social media usage, and physician review website variables for spine surgeons across Healthgrades.com (Healthgrades), Vitals.com (Vitals), and Google.com (Google).METHODSThrough a directory of registered North American Spine Society (NASS) physicians, we identified spine surgeons practicing in Texas (107 neurosurgery trained, 192 orthopedic trained). Three physician rating websites (Healthgrades, Vitals, Google) were accessed to obtain surgeon demographics, training history, practice setting, number of ratings/reviews, and overall score (January 2, 2018-January 16, 2018). Using only the first 10 search results from Google.com, we then identified whether the surgeon had a website presence or an accessible social media account on Facebook, Twitter, and/or Instagram.RESULTSPhysicians with either a personal or institutional website had a higher overall rating on Healthgrades compared to those who did not have a website (p < 0.01). Nearly all spine surgeons had a personal or institutional website (90.3%), and at least 1 accessible social media account was recorded for 43.5% of the spine surgeons in our study cohort (39.5% Facebook, 10.4% Twitter, 2.7% Instagram). Social media presence was not significantly associated with overall ratings across all 3 sites, but it did significantly correlate with more comments on Healthgrades. In multivariable analysis, increasing surgeon age was significantly associated with a lower overall rating across all 3 review sites (p < 0.05). Neurosurgeons had higher overall ratings on Vitals (p = 0.04). Longer wait times were significantly associated with a lower overall rating on Healthgrades (p < 0.0001). Overall ratings from all 3 websites correlated significantly with each other, indicating agreement between physician ratings across different platforms.CONCLUSIONSLonger wait times, increasing physician age, and the absence of a website are indicative of lower online review scores for spine surgeons. Neurosurgery training correlated with a higher overall review score on Vitals. Having an accessible social media account does not appear to influence scores, but it is correlated with increased patient feedback on Healthgrades. Identification of ways to optimize patients' perception of care are important in the future of performance-based medicine.

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HYPOTHESIS: Percutaneous pedicle screw fixations (PPSF) are increasingly used in spine surgery, minimizing morbidity through less muscle breakdown but at the cost of intraoperative fluoroscopic guidance that generates high radiation exposure. Few studies have been conducted to measure them accurately. MATERIAL AND METHODS: The objective of our study is to quantify, during a PPSF carried out in different experimented centers respecting current radiation protection recommendations, this irradiation at the level of the surgeon and the patient. We have prospectively included 100 FPVP procedures for which we have collected radiation doses from the main operator. For each procedure, the doses of whole-body radiation, lens and extremities were measured. RESULTS: Our results show a mean whole body, extremity and lens exposure dose per procedure reaching 1.7±2.8µSv, 204.7±260.9µSv and 30.5±25.9µSv, respectively. According to these values, the exposure of the surgeon's extremities and lens will exceed the annual limit allowed by the International Commission on Radiological Protection (ICRP) after 2440 and 4840 procedures respectively. CONCLUSION: Recent European guidelines will reduce the maximum annual exposure dose from 150 to 20mSv. The number of surgical procedures to not reach the eye threshold, according to our results, should not exceed 645 procedures per year. Pending the democratization of neuronavigation systems, the use of conventional fluoroscopy exposes the eyes in the first place. Therefore they must be protected by leaded glasses. LEVEL OF PROOF: IV, case series.

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