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Tobias A. Mattei and Daniel R. Fassett

), one of the main criticisms of minimally invasive spine surgery procedures. Finally, the availability of the O-arm offers the unique possibility of checking the positioning of the pedicle screws before final closure of the surgical wound, virtually eliminating the necessity of revision surgeries for screws repositioning. Although the accuracy of O-arm navigation–guided screw placement has reached as high as 97.5% in some series, this “final check” CT scan before closure has been demonstrated to lead to repositioning of approximately 1.8% of the screws placed under

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Jian Guan, Chad D. Cole, Meic H. Schmidt and Andrew T. Dailey

reduction in overall cost. Although our study examines a modestly different patient group—thoracolumbar deformity patients who had fusions more than 7 levels in length and with fewer revision surgeries—our findings appear to support theirs. Patients in our cohort who received ROTEM-guided blood transfusion management had significantly lower in-hospital blood transfusion needs. One possible explanation for this difference is the use of a more targeted or timely transfusion of blood products in the ROTEM group compared with the non-ROTEM group. For example, a patient who

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Marcus D. Mazur, Vijay M. Ravindra, Meic H. Schmidt, Darrel S. Brodke, Brandon D. Lawrence, Jay Riva-Cambrin and Andrew T. Dailey

, reason for lumbopelvic fixation, number of levels fused, placement of an L5–S1 interbody graft, use of bone morphogenetic protein (BMP), and whether an osteotomy was performed. The reason for lumbopelvic fixation was categorized as 1) primary surgery for scoliosis or degenerative disease; 2) revision surgery for failed lumbar fusion, symptomatic pseudarthrosis, or iatrogenic flat-back syndrome; or 3) primary surgery for osteolytic pathology, such as an infection or tumor (i.e., chordoma). Surgical Technique A standard midline posterior incision was made, and the

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Michael G. Kaiser, Jason C. Eck, Michael W. Groff, Zoher Ghogawala, William C. Watters III, Andrew T. Dailey, Daniel K. Resnick, Tanvir F. Choudhri, Alok Sharan, Jeffrey C. Wang, Sanjay S. Dhall and Praveen V. Mummaneni

demonstrated a positive impact on fusion rate; however, there is insufficient evidence regarding its impact on clinical outcome (single Level III study/multiple Level IV studies). Grade I There is insufficient evidence to recommend for or against the use of PEMFS as a treatment alternative to revision surgery in patients presenting with pseudarthrosis following posterior lumbar fusion (single Level IV study). Rationale Since the publication of the original “Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine,” 16 the

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Michael W. Groff, Andrew T. Dailey, Zoher Ghogawala, Daniel K. Resnick, William C. Watters III, Praveen V. Mummaneni, Tanvir F. Choudhri, Jason C. Eck, Alok Sharan, Jeffrey C. Wang, Sanjay S. Dhall and Michael G. Kaiser

The utilization of pedicle screw fixation as an adjunct to posterolateral lumbar fusion (PLF) has become routine, but demonstration of a definitive benefit remains problematic. The medical evidence indicates that the addition of pedicle screw fixation to PLF increases fusion rates when assessed with dynamic radiographs. More recent evidence, since publication of the 2005 Lumbar Fusion Guidelines, suggests a stronger association between radiographic fusion and clinical outcome, although, even now, no clear correlation has been demonstrated. Although several reports suggest that clinical outcomes are improved with the addition of pedicle screw fixation, there are conflicting findings from similarly classified evidence. Furthermore, the largest contemporary, randomized, controlled study on this topic failed to demonstrate a significant clinical benefit with the use of pedicle screw fixation in patients undergoing PLF for chronic low-back pain. This absence of proof should not, however, be interpreted as proof of absence. Several limitations continue to compromise these investigations. For example, in the majority of studies the sample size is insufficient to detect small increments in clinical outcome that may be observed with pedicle screw fixation. Therefore, no definitive statement regarding the efficacy of pedicle screw fixation as a means to improve functional outcomes in patients undergoing PLF for chronic low-back pain can be made. There appears to be consistent evidence suggesting that pedicle screw fixation increases the costs and complication rate of PLF. High-risk patients, including (but not limited to) patients who smoke, patients who are undergoing revision surgery, or patients who suffer from medical conditions that may compromise fusion potential, may appreciate a greater benefit with supplemental pedicle screw fixation. It is recommended, therefore, that the use of pedicle screw fixation as a supplement to PLF be reserved for those patients in whom there is an increased risk of nonunion when treated with only PLF.

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Zoher Ghogawala, Robert G. Whitmore, William C. Watters III, Alok Sharan, Praveen V. Mummaneni, Andrew T. Dailey, Tanvir F. Choudhri, Jason C. Eck, Michael W. Groff, Jeffrey C. Wang, Daniel K. Resnick, Sanjay S. Dhall and Michael G. Kaiser

rhBMP-2 or ICBG. Outcomes &costs were assessed at 2 yrs. SF-6D was used for utility measurements. Follow-up was 96%. Nosensitivity analysis. The cost of fusion using rhBMP-2 was $39,967. Fusion w/ ICBG cost $42,286. In the ICBG group, there were 5 revision surgeries; in the rhBMP-2 cohort, 1 revision surgery. The 2 cohorts had similar improvement in SF-6D scores. The cost of using rhBMP-2 is comparable to the cost of autograft for lumbar fusion surgery pts. Glassman et al., 2008 IV 106 pts >60 yrs old randomized to either rhBMP-2 vs ICBG for anterior 1-level

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Daniel K. Resnick, Tanvir F. Choudhri, Andrew T. Dailey, Michael W. Groff, Larry Khoo, Paul G. Matz, Praveen Mummaneni, William C. Watters III, Jeffrey Wang, Beverly C. Walters and Mark N. Hadley

analysis of patients who do and do not suffer from postoperative chronic low-back pain (case control study) could potentially provide Class II medical evidence to support the use of fusion in the subgroup of patients in whom there is likely to be a benefit. Abbreviation used in this paper PLF = posterolateral fusion . References 1. Baba H , Chen Q , Kamitani K , et al : Revision surgery for lumbar disc herniation. An analysis of 45 patients. Int Orthop 19 : 98 – 102 , 1995 Baba H, Chen Q, Kamitani

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Sanjay S. Dhall, Tanvir F. Choudhri, Jason C. Eck, Michael W. Groff, Zoher Ghogawala, William C. Watters III, Andrew T. Dailey, Daniel K. Resnick, Alok Sharan, Praveen V. Mummaneni, Jeffrey C. Wang and Michael G. Kaiser

. of levels = 2). Heterogeneous: variable no. of levels, half w/ degenerative spondylolisthesis, some had previous surger, some smokers, age range 44–82 yrs. Used SF-36 & dynamic radiographs; 100% follow-up. Pseudarthrosis in 13 pts, leading to revision surgery in 1. Reports “nearly identical maximum improvement on SF-36” & no correlation btwn fusion & clinical outcome. Found no correlation btwn pseudarthrosis & clinical results. The lesser quality prospective study was downgraded to Level III because of the heterogeneous pt population. Djurasovic et al., 2011

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Jeffrey C. Wang, Andrew T. Dailey, Praveen V. Mummaneni, Zoher Ghogawala, Daniel K. Resnick, William C. Watters III, Michael W. Groff, Tanvir F. Choudhri, Jason C. Eck, Alok Sharan, Sanjay S. Dhall and Michael G. Kaiser

of Odom's criteria. Patients undergoing a fusion demonstrated significantly better outcomes with respect to low-back pain. The frequency of revision surgery was significantly higher in patients who did not receive a fusion, but met the criteria for fusion. Interestingly, those patients who did not fulfill the criteria for fusion but had a fusion surgery also had significantly better results in terms of low-back pain scores compared with those without fusions. The authors concluded with this Level IV study that patients with disc herniations and instability or

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Daniel K. Resnick, Tanvir F. Choudhri, Andrew T. Dailey, Michael W. Groff, Larry Khoo, Paul G. Matz, Praveen Mummaneni, William C. Watters III, Jeffrey Wang, Beverly C. Walters and Mark N. Hadley

there is an increased risk of nonunion when treated with PLF. High-risk patients include, but are not limited to patients who smoke, who are undergoing revision surgery, or who suffer systemic diseases known to be associated with poor bone healing. Key Directions for Future Research The most important issue confronting the surgeon when deciding whether to use a particular surgical adjunct is the existence of any evidence that the inclusion of that adjunct improves functional outcome. Whereas it is clear that the addition of pedicle screw fixation improves