NASS 2022 Highest-Rated Abstracts
The NASS 2022 Scientific Program Committee received a record high 1,487 abstracts.
The 23 highest-rated abstracts earned the coveted 'Best Paper' designation and will be presented throughout the meeting.
Wednesday's Best Papers
Early versus delayed surgery for incomplete cervical spinal cord injury with pre-existing cervical stenosis: The OSCIS randomized clinical trial – Presenting Author: Hirotaka Chikuda, MD, PhD
  1. What question is your research attempting to answer?
    Despite the recent momentum for urgent surgery, the optimal treatment strategy for patients sustaining for acute traumatic incomplete cervical spinal cord injury (SCI) remains unclear, in particularly for those without bone injury. Little high-quality evidence is available on this long-debated issue. We therefore conducted a multicenter randomized trial to answer the clinical question: Does early surgical decompression (<24 hours after admission) yield better neurological recovery than delayed surgery (later than 2 weeks) for those with preexisting cervical canal stenosis?

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    In this first randomized trial, early surgical treatment showed similar motor recovery at 1 year compared with delayed surgery but was associated with significantly higher motor scores during the first 6 months. These findings strongly suggest that early surgical decompression leads to accelerated recovery in those with preexisting canal stenosis.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    The efficacy of early surgical decompression in SCI patients without fracture or dislocation has not been clarified. The results of the OSCIS study makes a strong case for early surgery, demonstrating accelerated motor recovery with early intervention.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    Based on our findings, early surgical decompression would be utilized more for those with preexisting cervical canal stenosis to enhance their recovery. On the other hand, our data also suggest patients who underwent delayed surgery will catch up, albeit slowly, in the long run. Therefore, we believe a conventional wait-and-see strategy is still a reasonable option for high-risk patients with multiple comorbidities.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    In our pre-specified subgroup analysis, we found no additional benefit of early surgery in patients with central cord syndrome, who have graver paralysis in the upper limbs compared with the lower limbs. This is a rather unexpected finding and needs to be further confirmed. We also hypothesized that early surgery may alleviate patients’ pain after SCI; however, that was not the case. There was no difference between the groups in terms of the patients’ pain after SCI. We definitely need further research to find factors associated with pain after SCI.

Early versus (<24 hrs) late (=24 hrs) surgical decompression for central cord syndrome: A propensity score matched analysis of prospective, multicenter data – Presenting Author: Michael Fehlings, MD, PhD, FRCSC
  1. What question is your research attempting to answer?
    Central cord injury, a form of incomplete cervical spinal cord injury (SCI) characterized by greater impairment in the upper vs lower limbs, is now the most common form of SCI in developed countries. However, the role and timing of surgery for central cord injury remains controversial. This paper sought to address the question of how the timing of surgical decompression impacts neurological and functional outcomes in patients with central cord syndrome.

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    1. Early surgical decompression (< 24 hrs) resulted in superior recovery in upper limb motor function at 1 year, as compared with late decompressive surgery (>= 24 hrs).

    2. The beneficial effect of early surgical decompression was more pronounced in patients with AIS grade C injury.

    The implication of the above two findings is that treatment paradigms for CCS should be redefined to encompass early surgical decompression as a neuroprotective therapy.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    This is the largest study to date to examine the impact of early (< 24 hrs) versus late (>= 24 hrs) surgical decompression on sensorimotor recovery in patients with central cord syndrome. This study used high-quality prospectively collected data and a propensity score matching technique that adjusted for relevant confounders. As the population continues to age, the topic of central cord syndrome is increasingly relevant and delineating the optimal treatment strategy for this pattern of injury is a key public health priority.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    This research would help revise clinical practice guidelines to support early surgical decompression in the setting of central cord syndrome.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    Knowledge translation efforts are needed to translate these findings into a change in clinical practice.

Understanding the influence of prior positive COVID-19 infection on 90-day outcomes following elective lumbar spine surgery – Presenting Author: Austin Roebke, MD
  1. What question is your research attempting to answer?
    We sought to study whether a previously positive COVID-19 infection in the 6 months prior to elective lumbar spine surgery had an impact on 90-day medical and surgical outcomes.

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    Patients with a COVID-19 infection in the 6 months preceding elective lumbar spine surgery had a higher association with 90-day rates of the following:

    1. Cardiac complications (3.3% vs. 1.1%, OR 2.75; p=0.021)
    2. Thromboembolic complications (6.0% vs. 2.3%, OR 2.35; p=0.014)
    3. Sepsis (5.3% vs. 2.0%, OR 2.31; p=0.024)

    COVID-19 infections in the general population have been shown to have cardiac and thromboembolic effects. This is the first spine specific study to show that patients who have recovered from a COVID-19 infection within the last 6 months and undergo elective lumbar spine surgery have higher rates of these complications.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    There is a growing body of evidence showing that patients undergoing urgent surgery, who are also COVID-19 positive, have increased postoperative mortality and morbidity. However, there is little known about patients who are COVID-19 negative at the time of surgery, but recently had a COVID-19 infection in the months preceding surgery. This study shows an association between increased complications/morbidities and those with a recent COVID-19 infection at the time of elective lumbar spine surgery.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    This research will hopefully spur further higher-level research looking at the safety of patients who recently had a COVID-19 infection undergoing spine surgery. If a recent COVID-19 infection is confirmed as a modifiable risk factor for increased complications after elective lumbar spine surgery, the delay of surgical intervention for these patients may lead to better outcomes for our surgical spine patients.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    Certainly, more follow-up research (level 1 evidence, non-database cohort, etc.) is needed to confirm the findings in this study.

    Spine specialists armed with this data should take extra care in indicating patients with cardiac or thromboembolic comorbidities with a recent COVID-19 infection for elective lumbar surgery. They may also counsel patients during their informed consent that they may have a higher rate of these complications.
Clinical outcome of lumbar hybrid surgery in a consecutive series of patients including long term follow up – Presenting Author: Jessica Shellock, MD
  1. What question is your research attempting to answer?
    We wanted to assess the long-term clinical outcome for patients undergoing lumbar hybrid surgery (total disc replacement (TDR) at one level and fusion at another level) in the treatment of symptomatic lumbar degenerative disc disease (DDD) at multiple levels.

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    In a series of 296 consecutive patients undergoing lumbar hybrid surgery there were statistically significant improvements in the mean values of all three clinical outcome measures evaluated (VAS leg, VAS back, ODI). There was no significant differences in the pain and function scores for patients with minimum 10-year follow-up versus those with shorter follow-up duration. This supports the durability of the improvements over time.

    The most common reason for reoperation in this series was removal of painful posterior instrumentation at the fusion level of the hybrid, not related to the disc replacement.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    Our results support that lumbar hybrid surgery is a viable option for patients with symptomatic multi-level lumbar DDD.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    Many patients with symptomatic lumbar DDD at multiple levels may have some levels that are not amenable to TDR and would be better addressed with a lumbar fusion. This paper supports the option of a hybrid procedure for patients in this situation and shows that there is significant clinical improvement in all of the outcome measures evaluated for this population.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    I believe that spine surgeons should use this information, and hopefully more information to continue to support these findings, to appeal to insurance carriers to get coverage for hybrid procedures. As of now, hybrid surgery is considered ‘experimental’ for most, if not all, carriers.

Cellular aging for risk stratification in adult deformity surgery: Utilization of 7 epigenetic clocks and 2 telomere length measurements in the analysis of comorbidity burden, frailty, disability, and complications in adult deformity surgery – Presenting Author: Michael Safaee, MD
  1. What question is your research attempting to answer?
    Our team is interested in improving the quantification of physiologic reserve using biomarkers of cellular age. We previously showed that short telomere length was associated with increased rates of postoperative complications in patients undergoing deformity surgery. This study builds upon that work by assessing the role of epigenetic clocks to assess comorbidities, frailty and complications.

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    In a prospective cohort of 43 adult patients undergoing spinal deformity surgery, biological age was associated with Charlson comorbidity index scores using six independent epigenetic clocks. Frailty index was associated with the DenedinPACE epigenetic clock, which also showed a trend towards correlation with Oswestry Disability Index. Both direct and indirect telomere length measurements were associated with 90-day complications, while only one epigenetic clock showed a trend towards statistical significance. These data show that markers of biologic or cellular age correlate with common measurements of comorbidity burden, frailty and postoperative complications. This provides compelling impetus to expand this work and determine how to best utilize markers of biological age in risk stratification for elective spine surgery.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    This work is the first to correlate epigenetic age and frailty scores in a prospect cohort of patients undergoing spine surgery. We are beginning to accumulate data suggesting that cellular and genetic age are more important than chronological age when assessing perioperative risk and may improve current risk stratification models.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    Our goal is to identify biomarkers of cellular aging that can improve our current ability to quantify perioperative risk. These data will improve the informed consent process, guide surgical planning, and allow for more accurate risk stratification by both providers and payers.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    We must expand this work to all patients receiving spine care to better understand how to interpret markers of cellular age and better define their role in risk assessment and current treatment algorithms.

International perspectives on the current practice of acute spinal cord injury management: Results of a global survey – Presenting Author: Nader Hejrati, MD
  1. What question is your research attempting to answer?
    Despite the need to integrate knowledge generated by research into clear guidelines, there remains an inherent tension between incomplete certainty regarding the use of steroids, optimal hemodynamic management, the timing of surgical decompression and optimizing acute SCI care in real-world circumstances. The continuing uncertainty affects the extent of guideline implementation and is further accentuated in an increasingly heterogeneous SCI patient population, with some patients seemingly more suitable for certain therapeutic strategies than others.

    The objective of this study was to examine knowledge, adoption and challenges in the implementation of standardized practices of spine care professionals regarding the acute administration of steroids, hemodynamic management and timing of surgical decompression in acute SCI.

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    This survey highlights challenges in the implementation of standardized practice regarding the use of steroids, hemodynamic management and early surgical intervention. Three key findings underpin the necessity to address logistic and infrastructural barriers as well as gaps in knowledge transfer in future studies:

    a) Despite clear evidence for surgeon preference to implement a "Time is Spine" approach (88%), the majority of spine care professionals encounter logistical barriers (62%) in the implementation of early surgery within 24 hours. Notably, those barriers result in an increased likelihood of delayed surgery, particularly in Low and Middle Income Countries (LMICs), (58%).

    b) Patients in LMICs are significantly less likely to be provided with mean arterial pressure (MAP) targeted therapy (77%) compared to High Income Countries (HICs) (89%, p < 0.01). The most common reasons not to provide MAP-targeted treatment to patients with acute SCIs are logistical barriers, such as lack of intensive care unit (ICU) beds or monitoring capacity.

    c) Ongoing controversies surrounding the role of steroids are reflected in this study, where 54% of spine care professionals administer steroids in the management of acute SCI, while 46% do not.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    Our results demonstrate real-world challenges in the implementation of standardized practice despite increasing evidence supporting the concept of early surgical intervention and the role of hemodynamic management.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    Important findings from this study will complement our current knowledge translation and upcoming guidelines efforts. Future research will need to focus on guideline implementation barriers, such as logistic hurdles in the implementation of early surgery (inter-hospital transfers, in-hospital administrative/logistic barriers, access to medical imaging, etc.) or allocation of limited resources for SCI patients in need of hemodynamic therapy (such as ICU beds, monitoring capacity, trained personnel). Moreover, this work highlights the importance of continuing to refine guidelines and strengthening modalities of knowledge transfer, as the rapidly evolving realm of SCI research continues to produce pivotal evidence.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    The AO Spine SCI Knowledge Forum is currently working on updated guidelines for the management of acute SCI. This important work will inform the current guideline development efforts, where a particular emphasis will be put on barriers to acute SCI care.
Return to work, activities of daily living and disability improvement: Twelve-month outcomes of an FDA IDE trial of decompression and tension band stabilization for degenerative spondylolisthesis – Presenting Author: William Lavelle, MD
  1. What question is your research attempting to answer?
    Despite decompression with instrumented fusion being the established gold standard treatment for degenerative spondylolisthesis (DS), ongoing research continues to seek to determine whether fusion is truly superior to decompression alone, or whether certain patients with DS may be selected for decompression alone. The tradeoffs are that decompression with fusion has durable outcomes for the treated segment, however fusion is costly, invasive and may lead to adjacent segment degeneration. Decompression alone initially relieves neurologic symptoms and is much less costly and invasive, however several studies have shown that decompression alone may not be as durable as fusion. Decompression and dynamic sagittal tether stabilization may balance these considerations by offering postoperative stabilization after decompression, with a motion-preserving option that is less invasive than fusion.

    Our work in this interim analysis assesses work status, time to return to work and activities of daily living and change in disability (ODI) 12 months postoperatively for patients receiving decompression and DST stabilization vs decompression and fusion.

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    The key findings from this study are that, compared to the standard of care decompression and fusion, the decompression and DST group had:

    a) Significantly faster return to work and ADLs
    b) Significantly lower rate of not working due to their spinal condition
    c) Significantly larger reduction in disability 12 months postoperatively

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    Our results demonstrate that DST stabilization after decompression may represent a feasible alternative to fusion for patients with symptomatic DS. The reduction in disability and faster return to work and ADLs may indicate lower perioperative morbidity and faster recovery similar to decompression, while sustained reduction in disability may indicate clinical durability similar to fusion.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    This research contributes to the body of knowledge around a new treatment alternative that may be preferable to patients for its faster recovery, probably lower costs and motion preservation compared to the dominant standard of care.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    Follow-up research into this technology is needed, including:

    - Reporting of the primary, composite endpoint with propensity score adjustment for the entire enrolled population.
    - Economic analyses to demonstrate the incremental cost effectiveness ratio (ICER) of this technology compared to the standard of care.
    - Longer-term follow-up of at least 5-years to demonstrate the durability of the treatment.

Perioperative complications associated with epidural injections followed by cervical decompression and fusion – Presenting Author: Husni Alasadi, BA
No information available.
Imaging outcome at 24-month follow up in a prospective, multicenter study of two-level cervical arthroplasty with a PEEK on ceramic artificial disc – Domagoj Coric, MD
No information available.
Thursday's Best Papers
Lumbar total disc replacement: Occurrence of device removal or revision surgery during a 20-year experience with 1,775 patients – Presenting Author: Richard Guyer, MD
  1. What question is your research attempting to answer?
    When lumbar total disc replacements were introduced, there was concern about the safety of these devices, particularly with the need for implant revision or removal, which requires a repeat anterior approach. We wanted to determine the rate of revision/removal in a large series of patients with long-term follow-up.

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    We found that the revision/removal rate was 1.5% during a follow-up averaging 89 months. Of more than 250 patients with verified follow-up of 15 or more years, only one patient (0.4%) underwent TDR removal and this was necessitated due to trauma and fracture.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    The study involved a very large number of patients at 1,775 and a mean follow-up of 89 months and maximum follow-up of 251 months. This duration gave us an opportunity to assess the long-term safety of disc replacement. What we didn’t see is of great importance, that is, there was not a number of late revisions/removals due to mechanical failure of the implants.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    Patients and surgeons can be comfortable that these devices have a good long-term safety profile.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    Surgeons can feel comfortable using artificial disc knowing that there is little risk of mechanical failure in the long-term.

An introductory investigation of standing postural control “error” and its relation to balance in adult spinal deformity surgery patients – Presenting Author: Damon Mar, MD
  1. What question is your research attempting to answer?
    Is there a way to quantify the effect of spinal deformity and realignment on a patient’s ability to actively maintain their balance in daily life and, if so, is there a way for it to provide clinically-relevant guidance for treatment decisions?

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    Using the proposed method of quantifying sway error, ASD patients exhibited significant elevation of short-term peaks, which may be indicative of increased fall risks as well as elevated long-term baseline (average) error, which may be indicative of increased balancing effort. The technique also indicated possible differences in postoperative changes of anterior and posterior directions which may relate to degree of sagittal correction. Strong correlation of estimated center-of-mass from the method indicates that it can be implemented with just a single force plate, which may be simpler to implement compared to motion-tracking systems in a standard clinical setting.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    Preliminary evidence suggests that surgical realignment of ASD has significant effects on reducing postural stabilization error which lends credence to the notion of improved balance in daily life. The inclusion of balance error metrics into existing functional assessments provides more robust and clinically relevant insight into patient-specific function. From a feasibility perspective, the proposed methodology can be implemented with a single force plate and requires nothing more from the patient than a brief period of natural standing.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    The findings of this study provide insight into how objective balance metrics can be tailored to relate to deformity-specific factors and also provides guidance in determination of what equipment is necessary to obtain it. Spine patients stand to benefit from a refined understanding of their specific balance characteristics as part of their clinical evaluations, both pre- and post-operatively, and in simplification of the process needed to obtain the information.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    As an introductory study, there is much more follow-up research needed on this topic. With our basic groundwork established, there is now a need for expanded collection of data among a larger patient populations and refinement in understanding of the proposed metrics to patient-specific factors such as severity of symptoms, deformity classification and treatment factors. With the continuing growth of balance assessments and related smart-device applications, spine specialists should be proactive in the questioning and evaluation of emerging techniques to insure proper clinical interpretation and relatability.

Effects of cannabinoids on spinal fusion in a rat model – Presenting Author: Harold Fogel, MD
  1. What question is your research attempting to answer?
    In light of the opioid epidemic and the broadening legalization of marijuana, medical marijuana is gaining traction among providers and patients as a non-opioid analgesic option. Despite this trend, the effects of D9-tetrahydrocannabinol (THC) and cannabidiol (CBD) on bone healing and, specifically, spinal arthrodesis, is unknown, and thus its safety and utility as an analgesic after spinal fusion is unknown. The overall goal of this study is to understand the effects of THC and CBD on bone healing after spinal fusion in a rat model.

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    The combination (THC and CBD) treatment group had the highest fusion rates, with 66.7% demonstrating full fusion and 33.3% demonstrating partial fusion. This was followed by the THC group demonstrating 60% of rats with full fusion, 20% with partial fusion and 20% with no fusion. Fusion rates were lower in the CBD and saline groups. Callus formation was more extensive in the THC and combination treatment groups on μCT 3D reconstruction and bone volume fraction was significantly higher for CBD and THC treatment groups compared to the saline group. Bone mineral density and tissue mineral density values were higher for all cannabis treatment groups compared to the saline group, though not statistically significant.

    Our study preliminarily demonstrates that CBD and THC have no adverse effects on bone regeneration and the rate of spinal fusion in rats, and therefore cannabis may be a safe opiate alternative for postoperative analgesia. Furthermore, cannabinoids may possess osteoinductive properties which require further investigation.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    To the best of our knowledge this is the first study to investigate the effects of THC and CBD on bone healing after spinal fusion in a rat model. While there are no randomized or prospective clinical trials on the use of cannabis derivatives in orthopaedic patients, some retrospective and cross-sectional data does suggest there may be utility in using cannabis to treat pain related to orthopedic problems and surgery. This study sets the foundation for answering whether cannabis products can safely be used as an analgesic after fusion procedures. Furthermore, cannabinoids may not only be harmless to bone healing, but may in fact be osteoinductive. This requires further investigation with additional studies.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    Prior literature has clearly documented the inhibitory effects of cigarette and tobacco smoking on bone healing. Conversely, the effects of cannabis products, in any form, is unknown. Understanding the effects of cannabis on bone healing will allow us to better counsel our patients on the safety and appropriateness of its use as an analgesic after spinal fusion procedures.

  5. Is follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    This is a novel study that sets the foundation for answering the important basic science and clinical question of what effect cannabinoids have on spinal fusions. Additional investigations are still needed before any definitive conclusions can be made and are currently underway in our lab.
Intraosseous basivertebral nerve ablation randomized control trial 24-month results – Presenting Author: Douglas Beall, MD
  1. What question is your research attempting to answer?

    The research is designed to answer the question of how safe and efficacious basivertebral nerve ablation is as compared to conventional nonsurgical management of chronic low back pain. The 24-month data is a follow-up of the 1-year data and is done to determine the durability of the initial results of the Intracept Trial.

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    The 2-year data after basivertebral nerve ablation showed significant improvements in pain (VAS) and function (ODI) that amounted to a 41-point decrease in pain and a 28.5-point improvement in function respectively. Overall, 72% of the patients achieved a reduction of pain of 50% or more and almost one-third were pain free at 2 years following their BVN ablation. The combined responder rate (patients improving both their pain and function) was almost 80% and there were also significant improvements in the patients’ quality of life parameters.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    This study showed significant improvements in pain, function and quality of life at all time points through 2 years in patients treated with basivertebral nerve (BVN) ablation along with an excellent safety profile. These results are consistent with previous studies including another Level I study comparing BVN ablation to sham treatment and a prospective single arm trial.

    Basivertebral is a novel technique that is effective for significantly improving pain and function in a patient population that has few other options and in whom surgical intervention often produces marginal results.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    Spine patients suffering from chronic axial back pain that is unrelated to spinal instability or scoliosis have few options other than conservative measures, spinal fusion or disc arthroplasty to treat their painful condition. Basivertebral nerve ablation has results that are comparatively better than any of the other treatments, is done as a minimally invasive image guided technique, appears to have permanent results and does not predispose the patient to additional surgery. Long-term studies show that patients responding to BVN ablation can have relief of symptoms up to five years or more after a single treatment.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    There have been consistent and durable improvements in pain and function shown in three clinical trials including two level I randomized control trials and one prospective single arm cohort study. Patients who participated in the Intracept trial comparing BVN ablation to conventional management and who were randomized to the non-procedural treatment arm were allowed to cross over to the BVN ablation arm at six months. These patients had results that were nearly identical to those who were treated initially with BVN ablation which indicates that there is no downside to either treating patients with traditional conservative care prior to BVN ablation or by going straight to the ablation.

    Given the substantial literature support and the promising results of BVN ablation, the main issue for introducing this treatment into common clinical practice is one of education and making it known that there is a relatively new, novel and effective way to treat patients suffering from chronic low back pain.

Clinical outcomes of C2 nerve root sacrifice and the feasibility of its preservation in patients with congenital atlantoaxial instability – Presenting Author: Madhivanan Karthigeyan, MS, MCh
  1. What question is your research attempting to answer?
    During posterior C1-C2 fusion, the C2 ganglion is a restricting factor to an easy access of C1-C2 joints, and the placement of C1 lateral mass screws. Both intentional C2 nerve root sectioning as well as its preservation have been described, and are still debatable. We studied the clinical outcome after C2 nerve root sectioning as well as the feasibility of its preservation in patients with congenital atlantoaxial dislocation.

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    A complex C1-C2 morphology with highly deformed joints was seen in about three-fourths of our patients. In 178 patients, the C2 nerve root was sectioned, and in those with C1-occipital condyle hypoplasia, highly oblique joints, incurved occiput, pseudofacets and anomalous vertebral artery, its preservation was relatively difficult. Although postoperative numbness, paresthesia and dysesthesia were present in 30.3%, 21.9% and 19.1% patients respectively, the symptoms were bothersome in none. Noticeably, 5.1% of the patients developed non-healing occipital ulcers, and many of them needed surgical intervention in the form of a flap cover or skin graft.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    In few patients after C2 nerve root sectioning, nonhealing occipital ulcers can occur, adding to the procedure-related morbidity.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    Though the C2 nerve root sectioning did not disable the quality of life in many, a subset of patients is prone for neuropathic ulcers. Therefore, its preservation should be attempted whenever feasible, such as in patients with less complex anomalies/ favorable anatomy.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    With the ongoing debate on the advantages and drawbacks of C2 nerve root sectioning/ preservation, a prospective randomized comparative trial of C2 nerve root preservation vs sectioning would better elucidate its impact on the clinical and radiological outcomes.

Predicting which patients receive early surgical decompression after traumatic spinal cord injury: An analysis of prospective multicenter data in 580 patients – Presenting Author: Ali Moghaddamjou, MD
  1. What question is your research attempting to answer?
    Given increasing evidence in support of the role of early surgical decompression in the treatment of Spinal Cord Injury (SCI), we set out to determine whether there is equity in the delivery of early surgical decompression in SCI patients.

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    Our analysis of prospective data revealed discrepancies in the delivery of surgical care when controlling for injury-specific factors. Non-Caucasian race, age and geographical remoteness all are associated with delays in surgical intervention which is one of the only proven treatments for SCI.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    This study is unique as it focuses on early surgery as the outcome leveraging large prospective databases of patients enrolled in SCI trials. The results raise concerns regarding equity in the treatment of SCI patients.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    The results of this study provide justification for the implementation of systemic transparent protocols to ensure all SCI patients have equal access to timely surgical care.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    This study is one of the first in its kind and calls for further research on issues of equity diversity and inclusion in SCI treatment. There are many unmeasured covariates at play that need further data and analysis. We are currently conducting additional analysis of SCI registries to better delineate specific socioeconomic factors that may be causing the discrepancies seen.

Usage trends and safety profile of recombinant human bone morphogenetic protein-2 for spinal column tumor surgery: A national matched analysis – Presenting Author: Mohammad Munim, BS
  1. What question is your research attempting to answer?
    Our research aims to investigate national usage rates of recombinant human bone morphogenetic protein-2 – otherwise known as rhBMP-2 or simply BMP – in the context of spinal tumor surgery. BMP is a powerful bone growth factor that is commonly used to augment spinal fusions but has recently become controversial due to reports of clinical side effects such as radiculitis, ectopic bone formation, and, most worrisome, tumorigenesis. Thus, we additionally aim to examine BMP's association with postoperative complications, reoperations and carcinogenicity.

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    Our work identified over 11,000 surgical cases and demonstrated significantly declining national utilization rates of BMP in the context of spinal tumor surgery, with the most recent annualization rate of 1.1% in 2020. We also observed increased rates of surgical site and systemic infections in spine tumor surgeries utilizing BMP. We observed no significant differences in survival, implant removal or reoperation rates. We also determined no significant association between BMP use and adverse oncologic effects.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    This work is exciting because of three main reasons. 1) it is the first big data national database study investigating the use of BMP in spinal tumor surgery, for which obtaining large cohort sizes has been characteristically difficult in prior literature. 2) We report that BMP use is nationally declining and attempt to answer why, which has not really been done by previous Authors. 3) We establish that BMP was not associated with significant oncologic concerns even in the spine tumor population, which is somewhat reassuring but its decline is certainly appropriate given the apparent risk of postoperative infections, which can be quite devastating especially in this vulnerable cohort.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    This research informs clinicians of up-to-date trends in spine tumor surgery and may help optimize surgical care in this vulnerable cohort. Recently the literature has questioned the role of fusion and fusion-augmenting technologies in this cohort, citing the lack of evidence suggesting that solid fusion truly offers better outcomes. One of the key selling points of this research is that BMP offered no significant benefits in implant survival or reoperation rate, which aligns with these recent efforts to conserve fusion-augmenting techniques in spine tumor patients. We also report on the increased rates of infection with BMP use, which may deter surgeons from using it in this context.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    Since this is a national database study, we are certainly limited by the scope of our investigation and the clinical extrapolation it provides. Further research is warranted to validate our findings from large multi-institutional prospective registries, where more granularity of the data may clarify deeper relationships between BMP exposure and adverse clinical effects.

Friday's Best Papers
Trends and epidemiology of cervical fractures in the United States, 2001-2020 – Presenting Author: Todd Turner, BS
  1. What question is your research attempting to answer?
    We are answering the question: what is the incidence and demographic characteristics of patients with cervical spine (c-spine) fractures over the past 20 years?

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    Our key findings include a 500% increase in the incidence of c-spine fractures over our 20-year study interval, population-adjusted incidence of c-spine fractures increased from 1.8 person-years at-risk (PYR) to 10.6 PYR, and the most common mechanism of injury was low energy falls (64%). This is clinically significant because orthopedic surgeons will likely be encountering significantly more c-spine fractures during trauma call and within their respective practices.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    The significant rise in the incidence of c-spine fractures was the most surprising result of the data, especially with our data being population-adjusted. Another surprising result of this study was how infrequent associated neurologic injury was in c-spine fracture patients (2.1%).

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    This study will benefit spine patients because it exposes an increasingly prevalent issue our elderly population is facing. By being aware that patients are more at risk for a c-spine fracture now than 20 years ago, providers can work with patients on fall prevention, education regarding c-spine fractures treatment and follow-up, and be more equipped to treat patients suffering this injury.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    There is more work that can help shine light on the topic of c-spine fracture incidence and the demographics of the patients sustaining these injuries. Future study should attempt to examine the why behind such a drastic increase in the incidence of these injuries. Why are patients suffering more low-energy falls now that cause c-spine fractures compared to 20 years ago? Now that specialists know this, they should attempt to spend more time addressing bone health and fall prevention with their elderly patients.

Utilizing big data to determine the safety profile of recombinant human BMP-2 in spinal fusion surgery: An analysis of 5 databases from 2003 to 2017 – Presenting Author: Don Park, MD
  1. What question is your research attempting to answer?
    Our study endeavored to determine the complication profile of bone morphogenetic protein (BMP) by combining multiple large databases and performing the largest independent analysis of BMP to date. We used 4 insurance claims databases including IBM MarketScan Commercial Claims, IBM MarketScan Medicare Supplemental, IBM MarketScan Medicaid, Optum ClinFormatics, and an electronic health record database, Optum Pan-Therapeutic. We investigated BMP at a large scale from its release into the market in 2003 to 2017 and examined the adverse effects of BMP in a large-scale longitudinal observation study.

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    We identified 60,427 patients who were administered BMP during spine fusion surgery and compared this cohort to 349,771 patients without BMP administration. We then investigated the rates of subsequent re-fusion surgeries, seroma/hematoma, postoperative infection, radiculitis, heterotopic bone formation and new cancer diagnosis for both cohorts. We used propensity scores to control for confounding in the comparisons between the cohorts. Hazard ratios (HR) were estimated for each outcome and we combined these estimates into a summary HR. We performed empirical calibration with negative and positive controls to quantify the systemic bias in our system and computed adjusted HR estimates and confidence intervals.

    We found that only postoperative infection had a statistically significant calibrated summary HR, which actually favored BMP administration. All other outcomes did not show any significant differences between BMP administration vs no BMP, including the development of any new cancer diagnoses. We performed a sub-analysis with benign and malignant cancer diagnoses and found there were no increased risk with the use of BMP in the development of these diagnoses.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    The surprising finding of our study’s results is that BMP was not associated with increased risk of adverse events during spinal fusion surgery. With the exception of postoperative infection, BMP administration had similar, non-statistically significant HRs as compared to non-BMP administration with all outcomes including any new cancer diagnoses. Our study was a large scale longitudinal observational study that produced a more credible estimate of a population-level effect of BMP. Our sophisticated statistical analyses controlled for confounding and more accurately estimated outcome effect sizes.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    This study can help add to the existing literature about the potential risks of utilizing BMP in spinal fusion surgery. The topic of BMP has been quite controversial, which has limited its use. We continue to advocate for judicious use of BMP in spinal fusion cases that would benefit the most. However, surgeons can be reassured that the appropriate use of BMP is safe for the adverse events that we investigated in this study.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    Further large-scale research studies with longer follow-up should be conducted to provide more long-term results on the topic. Our study selectively analyzed specific adverse events and other outcomes can be further investigated, such as medical complications and mortality.

Seven-year progression and 10-year prediction of adjacent level degeneration and disease after lumbar total disc replacement: A post hoc analysis of a prospective clinical trial with 7-year follow up – Presenting Author: Ernest Braxton, MD
  1. What question is your research attempting to answer?
    Our research is attempting to characterize the rate of adjacent level degeneration, both radiographic and clinical, in patients given lumbar TDR (ie, activL or ProDisc-L), over the long-term (ie, 7 to 10 years) and how this rate compares to that observed with lumbar fusion over a similar time frame.

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    We observed that the rate of progression of adjacent level degeneration (ALD) was observed to be relatively low over the 7-10 year time frame, particularly from a clinical perspective with <5% rate of reoperations performed due to ALD. The rates observed with lumbar TDR were no greater than that observed with conservative care in the published literature and were demonstrated to be statistically significantly lower than lumbar fusion through our indirect comparison. Finally, we observed that increased lumbar range of motion was associated with reduced progression of adjacent segment degeneration.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    There is a dearth of longer term data for adjacent segment degeneration outcomes in lumbar TDR patients. We employed advanced statistical techniques and predictive modeling to be able to conduct these analyses and compare lumbar TDR with fusion. These findings add further confirmation of the benefits of lumbar TDR over the long term and its favorable safety profile relative to fusion. These findings also help to confirm that implementation of these minimally invasive devices does not have adverse impacts on the adjacent spinal level as degeneration rates were observed to be comparable to non-operative care.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    As adjacent level degeneration can lead to important clinical outcomes such as pain and invasive reoperations, understanding how this outcome is characterized for TDR patients over the long term, and relative to fusion, can help inform decision-making for those patients with lumbar disc degeneration who are not responsive to conservative, non-operative treatment.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    Adjacent level degeneration outcomes evaluated beyond 7 years comparing currently used lumbar TDR technologies to fusion, in single-level lumbar disc degenerative disease patients, can help to validate the findings predicted in this analysis over 10 years.

Clinical significance of C1-C2 bone mineral density using quantitated computer tomography – Presenting Author: Jamie Baisden, MD
  1. What question is your research attempting to answer?
    Is there regional variation in bone mineral density (BMD) at C1-C2 based on QCT? How can the clinician apply these findings to improve constructs for spinal surgeries?

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    BMD in C1 is the highest at the anterior tubercle and the posterior tubercle/arch. The anterior and medial lateral masses have the lowest BMD within C1.

    BMD in C2 is the highest in the anterior tubercle, the posterior tubercle/arch, and the top of the odontoid. BMD is the lowest within the anterior and medial lateral masses of C2 and the mid vertebral body.

    BMD is the greatest at C1, and less at C2 compared to other cervical vertebrae.

    BMD may be used to help optimize cervical constructs for cervical stabilization.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    For anterior approach to C2: these results affirm anterior odontoid screw fixation for Type 2 fractures with an intact transverse ligament incorporating the distal portion of the screw in the most distal portion of the odontoid resides in the area with the highest bone density providing a secure fixation.

    For posterior approaches to C1 and C2 fractures with instability: these results suggest that for C1-C2 posterior constructs where screws are incorporated, the use of longer screws to extend the trajectory past the medial/anterior lateral mass where the BMD is the lowest into the higher BMD anteriorly to prevent loosening of the construct. Use of C1-C2 wiring techniques such as Sonntag, Brooks and Gallie provide incorporation of the higher BMD within the posterior tubercle/posterior arches of both C1 and C2 and should still be considered a useful technique for C1-C2 posterior stabilization based on the increased BMD.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    Reconsideration for “old-school” C1-C2 wiring techniques particularly in elderly patients with unstable fractures of C2 and/or C1 provides incorporation of the higher BMD within both C1 and C2 posterior tubercle /posterior arches, early stability, less instrumentation costs (Double Cable vs 4 screw/2 rod construct at C1-C2), less potential blood loss by avoiding the lateral venous plexus and the lateral exposure needed for C1 and C2 screw placement, less intraoperative X-ray exposure without the need for OR/Stealth, and typically less OR time while maintaining safety. In cases where the posterior tubercle/posterior arches are fractured and unavailable, C1-C2 screw placement needs to account for the lower BMD along the mid portions of the screw trajectory and avoid short screw placement and potential for a less secure construct.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    Despite the older wiring techniques having been surpassed by the various newer C1-C2 screw fixation techniques, there is still a role for keeping these older C1-C2 wiring techniques as part of a surgeon’s armamentarium. Both posterior fixation techniques are useful and the knowledge of BMD variations within C1 and C2 may help optimize outcomes.

Opioid sparing anesthesia for adult spinal deformity surgery reduces postoperative pain, length of stay, ICU stay, opioid consumption, and opioid related complications: A propensity matched analysis – Presenting Author: Jeffrey Gum, MD
  1. What question is your research attempting to answer?
    First, we now know that opioids have some terrible side effects and long-term consequences. The statistics are mind blowing when looking at our current opioid epidemic (happy to expand on this). We also have seen pretty awful data within the context of spine. Some reports state that as high as 20% of opioid naive patients undergoing elective spine surgery are still taking opioids at 1-year postop. That is terrible! That means we (spine surgeons) are contributing to the problem! So, we have spent the last few years really trying to minimize opioid exposure to our patients.

    This study evaluates an opioid free or sparing anesthesia protocol (OFA/OSA) in adult spine deformity surgeries. Our protocol essentially allows us to perform these surgeries and give no to very little opioids. We found that almost every postop recovery metric we looked at was improved. They get up quicker, less blood loss, less transfusions, out of the hospital quicker, less complications, etc. Overall, just a much safer way to perform spine surgery especially the bigger surgeries.

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    See above.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    The results affirm what we expected. We knew/observed that they were doing much better clinically but when we ran the analysis it was very obvious.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    Our goal is to make a protocol that is generalizable and easy to apply. My anesthesia team covers 150+ hospitals and we are in the process of streamlining the protocol so any spine center can start using it ASAP. We want to minimize exposure to opioids to every spine patient across the world to give better immediate outcomes and minimize the chance of dependence/addiction down the road. Additionally, the NIH and NIDA (government agencies) have identified the opioid crisis as a huge priority and are pushing tons of resources/funding to combat this crisis. So, these results help those efforts.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    We want to move to a multi-center, prospective study to confirm its generalizability and ease of incorporation. And not just in ASD but in all spine surgeries. We have previously presented the same data in degenerative conditions/surgeries with similar results. We are in the process of publishing this data currently.

Bone on the back table: Effects of autograft handling on spinal fusion – Presenting Author: Gregory Mundis, MD
No information available.
Anterior lumbar spinal fusion perioperative morbidity and mortality utilizing the National Inpatient Sample (NIS): 2005-2013 – Presenting Author: Stephen Saela, MD
No information available.