During the pandemic of COVID-19, some patients with COVID-19 may need emergency surgeries. As spine surgeons, it is our responsibility to ensure appropriate treatment to the patients with COVID-19 and spinal diseases. A protocol for spinal surgery and related management on patients with COVID-19 has been reviewed. Patient preparation for emergency surgeries, indications, and contraindications of emergency surgeries, operating room preparation, infection control precautions and personal protective equipments (PPE), anesthesia management, intraoperative procedures, postoperative management, medical waste disposal, and surveillance of healthcare workers were reviewed. It should be safe for surgeons with PPE of protection level 2 to perform spinal surgeries on patients with COVID-19. Standardized and careful surgical procedures should be necessary to reduce the exposure to COVID-19

Introduction. Following the publication of our original survey in 2000 (Eur. Sp. J. 11(6):515-8 2002) we have sought to re-evaluate the perceptions and attitudes towards spinal surgery of the current UK orthopaedic Specialist Registrars (SpRs), and to identify factors influencing an interest in spinal surgery. At that time 175 orthopaedic spinal surgeons in the UK needed to increase by 25% to satisfy parity with other European countries. Methods. A postal questionnaire was sent to all 917 SpRs. The questionnaire sought to identify perceptions in spinal surgery, levels of current training and practice, and intentions to pursue a career in spinal surgery. Results. A 61% response rate has confirmed that 74% of trainees intend to avoid spinal surgery (69% in 2000). However 10% are committed to become a Specialist Spinal Surgeon (6.5% in 2000). Their perceptions were wide ranging but most concluded that the intellectual challenge and opportunities for research are widely recognised. However enthusiasm is dampened by poor perceptions of outcomes from surgery, negative somatisation and depression associations, complications and the fear of litigation. In some areas there is inadequate exposure to spinal surgery during the first 4 years of training. Conclusions. Spinal surgery remains a career choice for 10% of surgical trainees (up 3.5% since 2000). With a large SpR expansion (578 to 917 SpRs in the last 5 years) an average of 9 new spinal surgeons annually will be produced over the next six years. This has improved on the figure of 6 per year from 2000. These figures suggest that by 2011 and allowing for retirement, there should be enough spinal surgeons to meet the desired UK/Europe ratio

Introduction. Many journals require outcome data at 2 years post-operative for the assessment of operative procedures in spinal surgery. This study seeks to clarify the timescale of improvement after surgery to see if a shorter period of assessment will indicate the final outcome. Methods. Outcome data for 185 consecutive patients who underwent spinal surgery was analysed. All were given a global outcome assessment questionnaire (as used in the Swedish Spinal Fusion study) at 6 months, 1 year and 2 years following surgery. Results were analysed according to the type of spinal surgery undertaken. Results. Six patients had incomplete data and were excluded. 124 of 179 patients were ‘much better’ or ‘better’ at 6 months. There was no significant change in the outcome of this group at 2 years (p<0.05). Only 18 showed any deterioration at 1 year and 2 years post surgery. Conclusion. Of the 55 patients who were ‘same’ or ‘worse’ at 6 months, most had no significant improvement in outcome at 2 years. Only 6 showed any significant improvement. Sixty four patients underwent disc replacement or spinal fusion. Of these, 19 patients improved between 6 months and 2 years follow-up. Eight patients got worse during the same period. Fifty eight patients underwent decompressive surgery. Of these 12 had a better outcome at 2 years than 6 months, and 17 had a worse outcome. Data from the remaining 57 patients was too heterogenous to analyse by subgroup

Introduction. Traditionally complex spinal surgery in Belfast has been performed at the Royal Victoria Hospital (RVH). Since an amalgamation the RVH has become effectively the level 1 trauma centre for the province. The ever increasing complexity of spinal surgery in addition to changes in practice such as the management of metastatic spinal cord, are placing significant demands on the service. At a time when resources are scarce trends in patient profiles are highly important to allow adequate planning of our service. Aim. To establish trends in patient profiles in a level one trauma centre also managing spinal pathology over the last 10 years and to examine the impact of this on our service. Methods. The Fracture Outcome Research Data base (FORD) was interrogated to provide data for patient profiles from 2000 to 2010. The Hospital planning and performance department contacted for finance data. Results. In 2000 the most common admission was for a fractured neck of femur (n=1014). This has not significantly changed over the ten years. In 2000 fractured tibia (n= 386), fractured forearms (n= 324), fractured ankles (n= 312) and spinal cases (n=335) were admitted. By 2010 a 49% increase had occurred in spinal admissions making them the second most common patient admitted to the unit. Of spinal case admissions, tumours have increased by 333%, spinal fractures by 10%, cervical disc surgery by 163% and suspected cauda equine cases by a staggering 537%. Conclusions. The throughput of spinal admissions to the unit has significantly increased between 2000 and 2010 making them now the second most common admission to the unit. The impact of this on bed days, theatre usage and oncall arrangements is huge and must be taken into account in stratregic planning of our service especially given the background of ongoing financial constraint

To introduce a new robot-assisted surgical system for spinal posterior fixation which called TiRobot, based on intraoperative three-dimensional images. TiRobot has three components: the planning and navigation system, optical tracking system and robotic arm system. By combining navigation and robot techniques, TiRobot can guide the screw trajectories for orthopedic surgeries. In this randomised controlled study approved by the Ethics Committee, 40 patients were involved and all has been fully informed and sign the informed consent. 17 patients were treated by free-hand fluoroscopy-guided surgery, and 23 patients were treated by robot-assisted spinal surgery. A total of 190 pedicle screws were implanted. The overall operation times were not different for both groups. None of the screws necessitated re-surgery for revised placement. In the robot-assisted group, assessment of pedicle screw accuracy showed that 102 of 102 screws (100%) were safely placed (<2 mm, category A+B). And mean deviation in entry point was 1.70 +/− 0.83mm, mean deviation in end point was 1.84 +/− 1.04mm. In the conventional freehand group, assessment of pedicle screw accuracy showed that 87 of 88 (98.9%) were safely placed (<2 mm, category A+B), 1 screw fall in category C, mean deviation in entry point was 3.73 +/− 2.28mm, mean deviation in end point was 4.11 +/− 2.31mm. This randomised controlled study verified that robot-assisted pedicle screw placement with real-time navigation is a more accuracy and safer method, and also revealed great clinical potential of robot-assisted surgery in the future

HIV and musculoskeletal trauma have reached epidemic proportions in the developing world especially in sub Saharan Africa. The epidemic has adversely affected health care delivery in limited resource settings. We assessed the outcome of HIV+ patients following spinal surgery for fractures and dislocations. Forty seven HIV+ patients were treated surgically over the past three years. The mean age was 32 years (19–53 years) and included 39 males. The dorsolumbar region was affected in 28 patients and the cervical spine in 19. Motor vehicle collisions (34) accounted for 72% of the injuries. Neurology occurred in 49% of patients (23). The mean CD4 count was 426 (range 98–742). The albumen was 29 gm/d? (range 26–34) and the lymphocyte count was 1.6c/cumm range 1.4–1.9). Twenty eight patients had generalized lymphadenopathy and recent weight loss was noted in 11 patients. Fifteen patients were treated for pulmonary TB and seven patients were on ARVs. The dislocations at the cervical spine commonly occurred at C5/6 (8). Three patients required a posterior cervical release with facetectomy prior to anterior cervical plating which was performed in all patients. The dislocations and unstable burst fractures of the dorsolumbar spine were treated by a one/two level posterior fusion. Post-operative sepsis due to S. aureus occurred in 8 (17%) patients. In four patients with deep infection vacuum dressings were used to clear the sepsis. Post-operative sepsis is best avoided by optimization of patients and meticulous surgery

Aim. Spinal infection is the most frequent complication of spine surgery. Its incidence varies between 1% and 14% in the literature, depending on various studied populations and surgical procedures. The aim of this study was to describe a consecutive 2706 case series. Method. We analyzed a prospective cohort of 2706 patients operated for spine disease between 2013 and 2016 in a University Hospital. The infection rates, germs, time between surgery and infection and outcomes after surgical revision were assessed with a minimum follow-up of 7 months. We developed a mathematical model to analyze risk factors in this difficult-to-treat population. Results. Among 2706 patient who underwent spinal surgery during the three-year study period, 106 developed a postoperative spine infection. Clinical indicators for infection were the sudden onset of local pain and swelling without fever after an initial pain-free interval. We observed a masculine predominance (68%); the median age was 56 years. The rate of infection was comprised between 0,3% (discal herniation surgery) to over 20% in posterior cervical instrumented surgery (acute cervical fractures), with a global rate of 4%. Polymicrobial infections with more than 3 germs were found in only 2 case, with 3 germs in 8 cases, 2 germs in 27 cases and 1 germ in 69 cases. Staphylococcus aureus, Propionibacterium acnes and Staphylococcus epidermidis were the three main germs identified (53, 36 and 22 respectively). Propionibacterium acnes was involved with a higher rate in instrumented surgery but also in 8% of conventional non-instrumented surgery, with a median relapse time of 24 days (12 days to 4 years). Staphylococcus aureus was involved at a higher rate in posterior non-instrumented surgery with a median relapse time of 18 days (8–66 days). The rate of infection per month was globally stable along the year except an increased rate in February-March. All patients with a suspicion of post-op infection were initially treated with wound/deep tissues revision within the first month after surgery and associated with implant removal after one-month post-op. Pejorative outcomes were associated with incomplete revision surgery, several surgeries and polymicrobial infection. Conclusions. In this study, the rate of postoperative infection is comparable to the literature. In contrast, Propionibacterium incidence is high, especially for acute infections. This unexpected rate can be linked to technical improvements in culture detection but this should also lead us to further discuss the natural process of spine/disk colonization of this germ

Introduction. Our clinic has started to use MAZOR's Spine-Assist(r) robotic device in routine spinal surgery practice since 2006. The use of this system is diverse and now applicable for Vertebroplasty, Biopsy procedures and different techniques of Spinal fusion. During this time our clinic performed near 150 robotic assisted surgeries. Amongst its benefits the system allows the reduction of the duration of fluoroscopic exposure in the OR, better accuracy due to computerized assisted planning and navigation, avoidance of human caused complications and a less traumatic procedure for the patient. On the other hand, the duration of the procedure is prolonged, the wound is subdued to a longer exposure in cases of the open surgery, and the operational cost is higher and requires a good trained medical staff. Materials and Methods. In the last 2 years we have performed 56 robotic assisted Vertebroplasty procedures (research group). At the same time we have performed 44 non assisted Vertebroplasty procedures. There was a significant difference in the fluoroscopic time and subsequent exposure time to radiation between the groups: in the research group we used only an average of 3 seconds of staff fluoroscopic exposure (an average of 5 fluoroscopic images) compared to an average of 11 seconds of exposure (an average of 24 fluoroscopic images). Furthermore, we have successfully inserted more than 400 pedical screws with less than 1mm accuracy from planning, out which only 8 were misplaced. Subsequently we have also performed 16 biopsies, which were effective as CT based biopsies. The average duration of a surgical procedure without the use of the system in 1 level fusion was 82 min. With the use of the system the average time was 106 min. The operational cost with the use of the system was about 1,000 ∊ more expensive. Furthermore, the use of the system required performing of an additional CT scan with 1 mm slices, which caused an additional exposure to patient radiation. Results. Robotic assisted spinal surgery is a new and safe approach aiming to dramatically shorten the duration of fluoroscopic exposure of the staff and surgeon thus reducing the exposure to radiogenic dose. This novel procedure, promotes a better accuracy with regard to Vertebroplasty, Spinal fusion, insertion of Pedical Screws and also for biopsies procedures. We continue to broaden the usage of the robotic assisted device to other fields of spinal surgery and to general orthopaedic surgery. However, we have to resolve some issues such as cost, operation time and less fluoroscopic exposure for the patient

Background. The Robotic Spinal Surgery System (RSSS) is a robot system designed for pedicle screw insertion containing image based navigation system, trajectory planning system and force state recognition system. The special force state recognition system can guarantee the safety during the operation. The RSSS is helpful in pedicle screw insertion surgery and it will be applied in clinic in the near future. In this study, we evaluated the accuracy and safety of RSSS in an animal experiment. Methods. Computer tomography (CT) scan data for two anesthetised experimental sheep was acquired using the C-arm and transferred to RSSS for pre-surgery screw trajectory planning. With the assist of RSSS, we inserted 8 and 4 screws into two sheep respectively. Operation time and blood loss during the surgery were recorded, and CT scan was repeated after surgery. Real screw position and trajectory acquired by the post-surgery CT scan and ideal trajectory planned by RSSS were compared to evaluate the accuracy and safety of RSSS. The result is shown as mean±SD. Results. We planted totally 12 screws into two sheep. The operation time for each sheep is 140min and 110min, and the blood loss is 100ml and 80 ml respectively. Compared with planned trajectory, the average deviation of the entry points in lateral and axial view are 1.07±0.56mm and 1.25±0.42mm and the mean screw deviation angles in later and axial view are 1.78±0.98°and 2.52±1.03°respectively. The RSSS successfully recognised the force stages and guaranteed the safety during the drilling process. There is no penetration in all 12 pedicles, and all the screws fell into group A according to the Gertzbein-Robbins classification. Conclusion. This animal study demonstrated the accuracy and safety of the RSSS, which also supported the potential application in clinic

Introduction

This study investigates the effect of somatisation on results of lumbar surgery.

Introduction. Evidence suggests that intra-operative spinal cord monitoring is sensitive and specific for detecting potential neurological injury. However, little is known about surgeons' responses to trace changes and the resultant neurological outcome. Objective. To examine the role of intra-operative somatosensory evoked potential (SSEP) monitoring in the prevention of neurological injury, specifically sensitivity and specificity, and whether the abnormalities were reversible. Methods. 2953 consecutive complex spine operations (male 36% female 64%, median age 25yrs) prospectively performed using spinal cord monitoring at a single institution (2005–2009). All traces and neurophysiological events were prospectively recorded by the neurophysiology technician. All patients with a significant neurophysiology event were examined clinically by a neurologist, separate from the spinal surgery team. Significant trace abnormality was defined as a decrease in signal amplitude of 50% or a 10% increase in latency. Timing of trace abnormality, surgeon's response and prospective neurological outcome were recorded. Sensitivity, specificity, positive/negative predictive value were calculated. A Chi-squared test was performed to assess the impact of intervention on neurological outcome (p < 0.05). Results. 2953 operations involving SSEP monitoring were performed and 106 recorded a significant trace abnormality. This most often occurred during instrumentation and the most common reaction was adjustment of metalwork. SSEP monitoring had a sensitivity of 100%, specificity 97.3%, PPV 24%, NPV 100%. There were 79 false positives and no false negatives in this series. Chi-squared test was not significant (p=0.18) suggesting that intervention might not affect neurological outcome in this cohort. Conclusions. Triggering events are uncommon and the development of a persistent neurological deficit is rare with an incidence of 0.85% in this series of 2953 operations. In the majority of cases detection of a monitoring abnormality prompts a corrective reaction by the surgeon. Of those with an abnormal trace 76% were neurologically normal at follow up

The incidence of MRSA infection is increasing worldwide. Costs incurred in treating MRSA infection are over twice that of normal patients, and the duration of hospital stay is up to 10 times longer. Risk factors are age, previous MRSA infection, prolonged hospitalization, patients from convalescent homes, immunocompromised states, vascular and pulmonary disease.

Purpose

To evaluate the efficacy of novel biodegradable MAACP/n-HA composite artificial lamina for the prevention of postlaminectomy adhesions and lamina reconstruction.

Spinal stenosis is a condition resulting in the compression of the neural elements due to narrowing of the spinal canal. Anatomical factors including enlargement of the facet joints, thickening of the ligaments, and bulging or collapse of the intervertebral discs contribute to the compression. Decompression surgery alleviates spinal stenosis through a laminectomy involving the resection of bone and ligament. Spinal decompression surgery requires appropriate planning and variable strategies depending on the specific situation. Given the potential for neural complications, there exist significant barriers to residents and fellows obtaining adequate experience performing spinal decompression in the operating room. Virtual teaching tools exist for learning instrumentation which can enhance the quality of orthopaedic training, building competency and procedural understanding. However, virtual simulation tools are lacking for decompression surgery. The aim of this work was to develop an open-source 3D virtual simulator as a teaching tool to improve orthopaedic training in spinal decompression. A custom step-wise spinal decompression simulator workflow was built using 3D Slicer, an open-source software development platform for medical image visualization and processing. The procedural steps include multimodal patient-specific loading and fusion of Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) data, bone threshold-based segmentation, soft tissue segmentation, surgical planning, and a laminectomy and spinal decompression simulation. Fusion of CT and MRI elements was achieved using Fiducial-Based Registration which aligned the scans based on manually placed points allowing for the identification of the relative position of soft and hard tissues. Soft tissue segmentation of the spinal cord, the cerebrospinal fluid, the cauda equina, and the ligamentum flavum was performed using Simple Region Growing Segmentation (with manual adjustment allowed) involving the selection of structures on T1 and/or T2-weighted scans. A high-fidelity 3D model of the bony and soft tissue anatomy was generated with the resulting surgical exposure defined by labeled vertebrae simulating the central surgical incision. Bone and soft tissue resecting tools were developed by customizing manual 3D segmentation tools. Simulating a laminectomy was enabled through bone and ligamentum flavum resection at the site of compression. Elimination of the stenosis enabled decompression of the neural elements simulated by interpolation of the undeformed anatomy above and below the site of compression using Fill Between Slices to reestablish pre-compression neural tissue anatomy. The completed workflow allows patient specific simulation of decompression procedures by staff surgeons, fellows and residents. Qualitatively, good visualization was achieved of merged soft tissue and bony anatomy. Procedural accuracy, the design of resecting tools, and modeling of the impact of bone and ligament removal was found to adequately encompass important challenges in decompression surgery. This software development project has resulted in a well-characterized freely accessible tool for simulating spinal decompression surgery. Future work will integrate and evaluate the simulator within existing orthopaedic resident competency-based curriculum and fellowship training instruction. Best practices for effectively teaching decompression in tight areas of spinal stenosis using virtual simulation will also be investigated in future work

Aim. Low-grade infections are difficult to diagnose. As the presence of a chronic infection requires extensive surgical debridement and antibiotic treatment, it is important to diagnose a SII prior to surgery, especially when the hardware is revised. We investigated whether serum inflammatory markers or nuclear imaging can accurately diagnose a chronic spinal instrumentation infection (SII) prior to surgery. Method. All patients who underwent revision spinal surgery after a scoliosis correction between 2017 and 2019 were retrospectively evaluated. The diagnostic accuracy of serum C-reactive protein (CRP) and Erythrocyte Sedimentation Rate (ESR), . 18. F-fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG-PET/CT) and Technetium-99m-methylene diphosphonate (99mTc-MDP) 3-phase bone scintigraphy (TPBS) to diagnose infection were studied. Patients with an acute infection or inadequate culture sampling were excluded. SII was diagnosed if ≥ 2 of the same microorganism(s) were isolated from intra-operative tissue cultures. Results. 31 patients were included. The indication for hardware extraction was pseudoarthrosis in the majority of patients (n = 15). 22 patients (71%) were diagnosed with SII. In all infected cases, Cutibacterium acnes was isolated, including 5 cases with a polymicrobial infection. Sensitivity, specificity, PPV and NPV was: 4.5%, 100%, 100% and 30.0% for CRP >10.0 mg/L, 5.5%, 100%, 100% and 29% for ESR > 30 mm/h; 56%, 80%, 83% and 50% for FDG-PET/CT and 50%, 100%, 100% and 20% for TPBS, respectively. Conclusions. The prevalence of SII in patients undergoing revision spinal surgery is high, with Cutibacterium acnes as the main pathogen. No diagnostic tests could be identified that could accurately diagnose or exclude SII prior to surgery. Future studies should aim to find more sensitive diagnostic modalities to detect low-grade inflammation

Introduction. This study aimed to assess the relationship between preparation times and operative procedures for elective orthopaedic surgery. A clearer understanding of these relationships may facilitate list organisation and thereby contribute to improved operating theatre efficiency. Methods. Two years of elective orthopaedic theatre data was retrospectively analysed. The hospital medical information unit provided de- identified data for 2015 and 2016 elective orthopaedic cases, from which were selected seven categories of procedures with sufficient numbers to allow further analysis - primary hip and knee replacement, spinal surgery, shoulder surgery (excluding shoulder replacement), knee surgery, foot and ankle surgery (excluding ankle replacement), Dupuytrens surgery and general orthopaedic surgery. The data analysed included patient age, ASA grade, operation, operation time, and preparation time (calculated as the time from the start of the anaesthetic proceedings to the patient's admission to Recovery, with the operating time [skin incision to skin closure] subtracted). Statistical analysis of the data was undertaken. Results. A total of 1596 procedures performed over the two year period were analysed. Preparation times for the different procedures were assessed, along with the relationship to the procedure complexity. Neither age nor ASA correlated strongly with preparation times. Spine procedures had greater preparation times than hip and knee arthroplasty. Greater uniformity in preparation times for hip and knee arthroplasty was seen across the anaesthetic group than operative times across the surgeon group. Discussion. Preparation times are just one aspect that may be evaluated with regard to theatre utilisation. This study did not address the theatre turn-over time between cases, which includes transfer of the patient from the admitting/pre-operative area into the theatre. Conclusion. Preparation times for elective procedures follow a pattern which may be used to inform list planning, with the potential for greater theatre efficiencies with regard to list utilisation and staff allocation

Low back pain is the single most common cause for disability in individuals aged 45 years or younger, it carries tremendous weight in socioeconomic considerations. Degenerative aging of the structural components of the spine can be associated with genetic aspects, lifetime of tissue exposure to mechanical stress & loads and environmental factors. Mechanical consequences of the disc degenerative include loss of disc height, segment instability and increase the load on facets joints. All these can lead to degenerative changes and osteophytes that can narrow the spinal canal. Surgery is indicated in patients with spinal stenosis who have intractable pain, altered quality of life, substantially diminished functional capacity, failed non-surgical treatment and are not candidates for non-surgical treatment. The aim was to determine the reasons for refusal of surgery in patients with established degenerative lumber spine pathology eligible for surgery. All patients meeting the study criteria, patients older than 18 years, patients with both clinical and radiological established symptomatic degenerative lumbar spine pathology and patients eligible for surgery but refusing it were recruited. Questionnaire used to investigate reasons why they are refusing surgery. Results 59 were recruited, fifty-one (86.4 %) females and eight (13.6 %) males. Twenty (33.8 %) were between the age of 51 and 60 years, followed by nineteen (32.2 %) between 61 and 70 years, and fourteen (23.7 %) between 71 and 80 years. 43 (72 %) patients had lumber spondylosis complicated by lumber spine stenosis, followed by nine (15.2 %) with lumbar spine spondylolisthesis and four (6.7 %) had adjacent level disease. 28 (47.4 %) were scared of surgery, fifteen (25.4 %) claimed that they are too old for surgery and nine (15.2 %) were not ready. Findings from this study outlined that patients lack information about the spinal surgery. Patients education about spine surgery is needed

Single level discectomy (SLD) is one of the most commonly performed spinal surgery procedures. Two key drivers of their cost-of-care are duration of surgery (DOS) and postoperative length of stay (LOS). Therefore, the ability to preoperatively predict SLD DOS and LOS has substantial implications for both hospital and healthcare system finances, scheduling and resource allocation. As such, the goal of this study was to predict DOS and LOS for SLD using machine learning models (MLMs) constructed on preoperative factors using a large North American database. The American College of Surgeons (ACS) National Surgical and Quality Improvement (NSQIP) database was queried for SLD procedures from 2014-2019. The dataset was split in a 60/20/20 ratio of training/validation/testing based on year. Various MLMs (traditional regression models, tree-based models, and multilayer perceptron neural networks) were used and evaluated according to 1) mean squared error (MSE), 2) buffer accuracy (the number of times the predicted target was within a predesignated buffer), and 3) classification accuracy (the number of times the correct class was predicted by the models). To ensure real world applicability, the results of the models were compared to a mean regressor model. A total of 11,525 patients were included in this study. During validation, the neural network model (NNM) had the best MSEs for DOS (0.99) and LOS (0.67). During testing, the NNM had the best MSEs for DOS (0.89) and LOS (0.65). The NNM yielded the best 30-minute buffer accuracy for DOS (70.9%) and ≤120 min, >120 min classification accuracy (86.8%). The NNM had the best 1-day buffer accuracy for LOS (84.5%) and ≤2 days, >2 days classification accuracy (94.6%). All models were more accurate than the mean regressors for both DOS and LOS predictions. We successfully demonstrated that MLMs can be used to accurately predict the DOS and LOS of SLD based on preoperative factors. This big-data application has significant practical implications with respect to surgical scheduling and inpatient bedflow, as well as major implications for both private and publicly funded healthcare systems. Incorporating this artificial intelligence technique in real-time hospital operations would be enhanced by including institution-specific operational factors such as surgical team and operating room workflow

Periprosthetic joint infection (PJI) occurs in 0.2-2% of primary hip and knee arthroplasty and is a leading cause of revision surgery, impaired function, and increased morbidity and mortality. Topical, intrawound vancomycin administration allows for high local drug concentrations at the surgical site and has demonstrated good results in prevention of surgical site infection after spinal surgery. It is a promising treatment to prevent infection following hip and knee arthroplasty. Prior studies have been limited by small sample sizes and the low incidence of PJI. This systematic review and meta-analysis was performed to determine the effectiveness of topical vancomycin for the primary prevention of PJI in hip and knee arthroplasty. A search of Embase, MEDLINE, and PubMed databases as of June 2020 was performed according to PRISMA guidelines. Studies comparing topical vancomycin to standard perioperative intravenous antibiotics in primary THA and TKA with a minimum of three months follow-up were identified. The results from applicable studies were meta-analysed to determine the impact of topical vancomycin on PJI rates as well as wound-related and overall complications. Results were expressed as odds ratios (ORs) and 95% confidence intervals. Nine comparative observational studies were eligible for inclusion. 3371 patients treated with 0.5-2g of topical vancomycin were compared to 2884 patients treated with standard care. Only one of nine studies found a significantly lower rate of PJI after primary THA or TKA (OR 0.09-1.97, p=0.04 for one study, p>0.05 for eight of nine studies), though meta-analysis showed a significant benefit, with vancomycin lowering PJI rates from 1.6% in controls to 0.7% in the experimental group (OR 0.47, p=0.02, Figure 1). Individually, only one of five studies showed a significant benefit to topical vancomycin in THA, while none of seven studies investigating PJI after TKA showed a benefit to topical vancomycin. In meta-analysis of our subgroups, there was a significant reduction in PJI with vancomycin in THA (OR 0.34, p=0.04), but there was no significant difference in PJI after TKA (OR 0.60, p = 0.13). In six studies which reported complication rates other than PJI, there were no significant differences in overall complication rates with vancomycin administration for any study individually (OR 0.48-0.94, p>0.05 for all studies), but meta-analysis found a significant difference in complications, with a 6.7% overall complication rate in controls compared to 4.8% after topical vancomycin, largely driven by a lower PJI incidence (OR 0.76, p=0.04). Topical vancomycin is protective against PJI after hip and knee arthroplasty. No increase in wound-related or overall complication rates was found with topical vancomycin. This meta-analysis is the largest to date and includes multiple recent comparative studies while excluding other confounding interventions (such as povidone-iodine irrigation). However, included studies were predominantly retrospective and no randomized-controlled trials have been published. The limited evidence summarized here indicates topical vancomycin may be a promising modality to decrease PJI, but there is insufficient evidence to conclusively show a decrease in PJI or to demonstrate safety. A prospective, randomized-controlled trial is ongoing to better answer this question. For any figures or tables, please contact the authors directly

Pain management in spine surgery can be challenging. Cannabis might be an interesting choice for analgesia while avoiding some side effects of opioids. Recent work has reported on the potential benefits of cannabinoids for multimodal pain control, but very few studies focus on spinal surgery patients. This study aims to examine demographic and health status differences between patients who report the use of (1) cannabis, (2) narcotics, (3) cannabis and narcotics or (4) no cannabis/narcotic use. Retrospective cohort study of thoracolumbar patients enrolled in the CSORN registry after legalization of cannabis in Canada. Variables included: age, sex, modified Oswestry Disability Index (mODI), Numerical Rating Scales (NRS) for leg and back pain, tingling/numbness leg sensation, SF-12 Quality of Life- Mental Health Component (MCS), Patient Health Questionnaire (PHQ-9), and general health state. An ANCOVA with pathology as the covariate and post-hoc analysis was run. The majority of the 704 patients enrolled (mean age: 59; female: 46.9%) were non-users (41.8%). More patients reported narcotic-use than cannabis-use (29.7% vs 12.9%) with 13.4% stating concurrent-use. MCS scores were significantly lower for patients with concurrent-use compared to no-use (mean of 39.95 vs 47.98, p=0.001) or cannabis-use (mean=45.66, p=0.043). The narcotic-use cohort had significantly worse MCS scores (mean=41.37, p=0.001) than no-use. Patients reporting no-use and cannabis-use (mean 41.39 vs 42.94) had significantly lower ODI scores than narcotic-use (mean=54.91, p=0.001) and concurrent-use (mean=50.80, p=0.001). Lower NRS-Leg pain was reported in cannabis-use (mean=5.72) compared to narcotic-use (mean=7.19) and concurrent-use (mean=7.03, p=0.001). No-use (mean=6.31) had significantly lower NRS-Leg pain than narcotic-use (p=0.011), and significantly lower NRS-back pain (mean=6.17) than narcotic-use (mean=7.16, p=0.001) and concurrent-use (mean=7.15, p=0.012). Cannabis-use reported significantly lower tingling/numbness leg scores (mean=4.85) than no-use (mean=6.14, p=0.022), narcotic-use (mean=6.67, p=0.001) and concurrent-use (mean=6.50, p=0.01). PHQ-9 scores were significantly lower for the no-use (mean=6.99) and cannabis-use (mean=8.10) than narcotic-use (mean=10.65) and concurrent-use (mean=11.93) cohorts. Narcotic-use reported a significantly lower rating of their overall health state (mean=50.03) than cannabis-use (mean=60.50, p=0.011) and no-use (mean=61.89, p=0.001). Patients with pre-operative narcotic-use or concurrent use of narcotics and cannabis experienced higher levels of disability, pain and depressive symptoms and worse mental health functioning compared to patients with no cannabis/narcotic use and cannabis only use. To the best of our knowledge, this is the first and largest study to examine the use of cannabis amongst Canadian patients with spinal pathology. This observational study lays the groundwork to better understand the potential benefits of adding cannabinoids to control pain in patients waiting for spine surgery. This will allow to refine recommendations about cannabis use for these patients