Study Design.: Global cross-sectional survey. Objective.: To validate the hierarchical nature of the AO Spine Upper Cervical Spine Injury Classification (UCIC) across AO geographical regions/practice experience. Summary of Background Data.: To create a universally validated scheme with prognostic value, AO Spine established an upper cervical spine injury classification involving three elements: injury morphology (region: I—occipital condyle and craniocervical junction; II—C1 ring and C1-2 joint; III—C2 and C2-3 joint), and (subtype: A—isolated bony injury; B—bony/ligamentous injury; C—displaced/translational injury), neurological status [N0—intact; N1—transient deficit; N2—radiculopathy; N3—incomplete spinal cord injury (SCI); N4—complete SCI, and NX—unable to examine], and case-specific modifiers (M1—injuries at risk of nonunion; M2—injuries at risk of instability; M3—patient specific factors; M4—vascular injury). Materials and Methods.: Totally, 151 AO Spine members (orthopaedic and neurosurgery) were surveyed globally regarding the severity (zero—low severity to 100—high severity) of each UCIC variable. Primary outcomes were differences in perceived injury severity score (ISS) over various geographic/practice settings, level of experience, and subspecialty. Results.: One hundred forty-eight responses were received. There was an increase in median perceived severity as each anatomic region (I–III) progressed from types A to B to C. Neurological status progressed similarly, except N1 and N2 were perceived similarly. Modifier M2 was perceived more severely than M3. There were no differences in ISS among levels of surgeon experience. There were small geographic differences with respondents from North and Central and South America perceiving types IC (P=0.003), IIB (P=0.003), and IIIB (P=0.003) somewhat more severely than other regions. Neurosurgeons perceived types IB (P=0.002) and IIIB (P=0.026) as more severe than orthopaedic spine surgeons. Conclusions.: The AO Spine UCIC has overall excellent hierarchical progression in subtype ISS. These findings are consistent across geographic regions, spine subspecialty training and experience levels.

Obese and African American populations suffer from higher incidence of hip and knee osteoarthritis, yet African Americans are less likely to undergo total hip and knee arthroplasty (TJA). Patient interest in TJA is a necessary first step for surgery. Medical device company direct-to-consumer advertising for TJA represents 1 potential factor driving disparities in utilization. Here we analyze demographics of models represented in medical device company direct-to-consumer TJA advertisements to understand whether advertisement content correlates with the population in need. We analyzed medical device company pamphlets, websites, and banner and video advertisements of the top 4 medical device companies in US arthroplasty sales, collected via ad-specific search engine and direct correspondence. Variables include model race, sex, age, and weight. Pearson likelihood ratio tests were used to compare categorical variables. Of the 116 advertisements collected, the model featured in the advertisement was white in 69.8%. The proportion of white models differed across medical device companies (company C, 75%) (P < .001) and advertisement type (video, 81.8%) (P < .001). Only 2.6% of advertisements featured obese models. Neither company C nor D, nor pamphlet or website advertisements used obese models. Direct-to-consumer advertising from the top 4 orthopedic US medical device companies does not represent the population in need: While TJA remains underutilized by African American/Hispanic patients, models were overwhelmingly white. While obese patients are known to need TJA, patients in the advertisements were overwhelmingly not obese. We advocate for medical device companies to refocus their advertising strategies to target diverse patients in need of TJA. III (retrospective cohort study).

Study Design: Retrospective cohort study. Objective: To analyze the ability of various quantitative, MRI-based measures of spine-specific sarcopenia to predict patient-reported outcomes following lumbar fusion surgery. Summary of Background Data: Sarcopenia is an established risk factor for poor outcomes and complications in spine surgery. However, a lack of consensus exists on how to optimally quantify paraspinal sarcopenia for outcome prediction. Furthermore, few studies have investigated the ability of MRI-based measures of sarcopenia to predict Patient-Reported Outcome Measure Information System (PROMIS), physical function (PF), and pain interference (PI) scores after lumbar fusion surgery. Methods: Included patients underwent lumbar fusion surgery at a single, tertiary academic center and had a lumbar MRI within 1 year before surgery. Demographic factors were collected, and lumbar paraspinal muscle (ie, multifidus, psoas, and erector spinae) cross-sectional area (CSA) and fatty infiltration (FI) were measured by 2 reviewers. All variables were compared on bivariable and multivariable analyses between patients who did versus did not meet a minimum clinically important difference (MCID) of 8 on PROMIS-PF and PROMIS-PI scores. Results: Of the 87 patients who met inclusion criteria, 59 patients met MCID for physical function (PF) while 57 patients met MCID for pain interference (PI). Bivariable analysis revealed no differences in demographic variables or CSA between MCID and non-MCID groups. Psoas FI demonstrated a trend towards significance for PROMIS-PF [MCID: 8.37 (±5.45) vs. non-MCID: 10.9 (±6.03), P =0.055], and baseline PROMIS-PI scores were higher in patients that met MCID for PROMIS-PI [67.2 (±4.79) vs. 62.9 (±7.78), P =0.005]. With multivariable analysis controlling for confounders, increasing psoas FI lowered the odds of meeting PROMIS-PF MCID (OR=0.90, P =0.033, 95% CI=0.82–0.99). Conclusions: Patients with increased psoas FI were less likely to see improvements in physical function after controlling for comorbidity burden and frailty. However, the effect size was relatively small.

Introduction Demographic disparities in musculoskeletal (MSK) health exist in the US. Racial representation in advertising has been shown to influence buying patterns. By focusing advertising toward majority groups, direct-to-consumer advertising may exacerbate MSK disparities by neglecting underrepresented minorities. To better understand how race is represented across MSK advertisements and how this may influence patterns in MSK health, we reviewed advertisements in popular magazines, using online databases for collection. Methods 8 magazine types were chosen. Racial distribution was analyzed using Pearson’s chi-squared and chi-squared goodness of fit tests. Fisher’s exact test was used when >20% of cells had n<5. Significance was set at p<0.05. Results Of advertisements that featured a model, white models were overrepresented (p<0.001), and Hispanic and Asian models were underrepresented (p<0.001). Only 7.3% of advertisements featured multiple models of different races or ethnicities, while 92.7% did not. African American models were overrepresented as athletes (p<0.001) and underrepresented in pain relief ads (p<0.001). Discussion There is poor representation of minorities in MSK advertisements. Even when controlling for US population demographics, white models were overrepresented, and models of minority races are underrepresented. African American models were typecast as athletes and underrepresented in pain relief ads.