Object Surgical correction of symptomatic cervical or cervicothoracic kyphosis involves the potential for significant neurological complications. Intraoperative monitoring has been shown to reduce the risk of neurological injury in scoliosis surgery, but it has not been well evaluated during surgery for cervical or cervicothoracic kyphosis. In this article, the authors review a cohort of patients who underwent kyphosis correction with multimodal intraoperative monitoring (MIOM). Methods Twenty-nine patients were included in the study. Preoperative and postoperative Cobb angles were measured to determine the extent of correction. Multimodal intraoperative monitoring consisted of somatosensory evoked potentials, transcranial motor evoked potentials (tMEPs), and electromyography activity. Sensitivity, specificity, positive predictive values (PPVs), and negative predictive values (NPVs) were assessed for each monitoring modality. Results The mean patient age was 58.0 years, and 20 patients were female. The mean pre- and postoperative sagittal Cobb angles were 41.3° and 7.3°, respectively. A total of 8 intraoperative monitoring alerts were observed. Transcranial MEPs yielded a sensitivity of 75%, specificity of 84%, PPV of 43%, and NPV of 95%. Somatosensory evoked potentials had a sensitivity of 25%, specificity of 96%, PPV of 50%, and NPV of 88%. Electromyography resulted in a sensitivity of 0%, specificity of 93%, PPV of 0%, and NPV of 96%. Changes in tMEPs led to successful intervention in 2 cases. There was 1 case in which a C-8 palsy occurred without any changes in MIOM. Conclusions In contrast to sensitivity and PPV, specificity and NPV were generally high in all 3 monitoring modalities. Both false-positive and false-negative results occurred. Transcranial MEP monitoring was the most useful modality and appeared to allow successful intervention in certain cases. Larger, prospective comparative studies are necessary to determine whether MIOM truly decreases the rate of neurological complications and is therefore worth the added economic cost and intraoperative time.

Objective: Recommendations for addressing sporting eligibility and disqualification in athletes with heart disease have traditionally used a paternalistic approach with cardiologists making a binary “yes-no” decision. This paradigm has recently evolved to a shared decision-making model recognizing and respecting the autonomy of the athlete while instituting safeguards to mitigate risk where possible. How well this paradigm is understood or has been integrated into the athletic trainer (AT) community is unknown. Design: Athletic trainers from the Ohio High School Athletic Association were surveyed. Results: Of 107 ATs who responded, we found that the majority had not heard of the term “shared decision-making” in the context of sporting participation [62.6%, confidence interval (CI) 0.53-0.72 vs 37.4%, CI 0.28-0.47]. Furthermore, we found large discrepancies as to how ATs would interpret and implement recommendations from cardiologists. Conclusions: This study highlights the need to educate and improve communication between AT, sports medicine physicians, and sports cardiologists if shared decision-making strategies are to become widely implemented.

Selective cytopheretic inhibitory device (SCD) therapy is an immunomodulatory treatment provided by a synthetic biomimetic membrane in an extracorporeal circuit, which has shown promise in preclinical large animal models of severe sepsis as well as in clinical trials treating patients with acute kidney injury and multiple organ failure. During SCD therapy, citrate is administered to lower ionized calcium levels in blood for anticoagulation and inhibition of leukocyte activation. Historically, citrate has been known to interfere with sorbent dialysis, therefore, posing a potential issue for the use of SCD therapy with a portable dialysis system. This sorbent dialysis SCD (sorbent SCD) would be well suited for battlefield and natural disaster applications where the water supply for standard dialysis is limited, and the types of injuries in those settings would benefit from SCD therapy. In order to explore the compatibility of sorbent and SCD technologies, a uremic porcine model was tested with the Allient sorbent dialysis system (Renal Solutions Incorporated, Fresenius Medical Care, Warrendale, PA, USA) and concurrent SCD therapy with regional citrate anticoagulation. The hypothesis to be assessed was whether the citrate load required by the SCD could be metabolized prior to recirculation from systemic blood back into the therapeutic circuit. Despite the fact that the sorbent SCD maintained urea clearance without any adverse hematologic events, citrate load for SCD therapy caused an interaction with the sorbent column resulting in elevated, potentially toxic aluminum levels in dialysate and in systemic blood. Alternative strategies to implement sorbent-SCD therapy will be required, including development of alternate urease-sorbent column binding chemistry or further changes to the sorbent-SCD therapeutic circuit along with determining the minimum citrate concentration required for efficacious SCD treatment.

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