Study Design: Narrative review. Objectives: To identify the risk factors and surgical management for recurrent lumbar disc herniation using a systematic review of available evidence. Methods: We conducted a review of PubMed, MEDLINE, OVID, and Cochrane Library databases using search terms identifying recurrent lumbar disc herniation and risk factors or surgical management. Abstracts of all identified articles were reviewed. Detailed information from articles with levels I to IV evidence was extracted and synthesized. Results: There is intermediate levels III to IV evidence detailing perioperative risk factors and the optimal surgical technique for recurrent lumbar disc herniations. Conclusions: Multiple risk factors including smoking, diabetes mellitus, obesity, intraoperative technique, and biomechanical factors may contribute to the development of recurrent disc disease. There is widespread variation regarding optimal surgical management for recurrent herniation, which often include revision discectomies with or without fusion via open and minimally invasive techniques.

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Study Design: This is a retrospective review of a single surgeon cervical deformity (CD) database. Objective: Quantitatively describe the cervical extensor musculature in a CD population, and delineate associations between posterior musculature atrophy and progressive sagittal deformity. Summary of Background Data: While fatty infiltration (FI; ie, posterior musculature atrophy) of lumbar extensor musculature has been associated with pain and deformity, little is known of the relationship between FI, CD, cervical sagittal alignment, and functionality. Methods: CD patients [TS-CL>20 degrees, C2–C7 Cobb>10 degrees, CL>10 degrees, cervical sagittal vertical axis (cSVA)>4 cm, or chin-brow vertical angle>25 degrees] 18 years old and above, undergoing spinal fusion, with baseline T2-weighted magnetic resonance images were included. FI was assessed using dedicated imaging software at each intervertebral level from C2–C7. FI was gauged as a ratio of fat-free muscle cross-sectional area over total muscle cross-sectional area, with lower values indicating increasing FI. Influence of BL C2–C7 FI on patient-reported outcome measures (PROMs) and alignment was investigated. Multiple linear regression analysis (covariates: age, sex, body mass index, C2–C7 FI ratio) determined predictors of postoperative sagittal alignment and PROMs. Results: Thirty-eight patients were included (age: 56.6, sex: 73.7% female, body mass index: 30.1, Charlson Comorbidity Index 0.61). BL deformity presentation: TS–CL 27.4 degrees, CL 2.1 degrees, cSVA: 27.2 mm. Mean baseline C2–C7 FI ratio was 0.65±0.11. Worsening FI was associated with malaligned baseline cSVA (r s=0.389, P=0.019), T1SS (r s=0.340, P=0.062), and impaired gait (r s=0.358, P=0.078). FI was not associated with BL PROMs (P>0.05). Following surgical intervention, regression models determined BL C2–C7 FI ratio as the strongest predictor of 1-year postoperative cSVA (β=−0.482, P=0.007, R 2=0.317). No associations between BL FI and postoperative PROMS or alignment parameters were observed (P>0.05). Conclusions: Patients with significant CD demonstrate alterations in the posterior extensor musculature of the cervical spine. Atrophic changes with FI of these muscle groups is associated with worsening CD and is an important predictor of postoperative sagittal alignment. Level of Evidence: Level III.

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* Metal hypersensitivity has been reported in various case reports and cohort studies. Type-IV (delayed-type) hypersensitivity to various implant metals, most frequently nickel, has been implicated in the pathogenesis of metal hypersensitivity.* Currently, there are no guidelines for addressing suspected or known metal allergy preoperatively and there is no evidence-based support for either preoperative testing or routine use of hypoallergenic implants.* Multiple diagnostic modalities are available for the workup of suspected metal hypersensitivity; the 2 most common are patch testing and lymphocyte transformation testing. However, the ability of these tests to diagnose disease and predict outcomes has not yet been demonstrated.* Further research is warranted to help understand the prevalence, pathology, diagnosis, treatment, and potential avoidance of metal hypersensitivity.

Background: YouTube has become a popular source for patient education, though there are concerns regarding the quality and reliability of videos related to orthopaedic and neurosurgical procedures. This study aims to evaluate the credibility and educational content of videos on YouTube related to cervical fusion. Secondarily, the study aims to identify factors predictive of higher or lower quality videos.Methods: A YouTube query using the search terms ''cervical fusion'' was performed, and the first 50 videos were included for analysis. Reliability was assessed using the Journal of the American Medical Association (JAMA) criteria. Educational quality was assessed using the Global Quality Score (GQS) and the Cervical Fusion Content Score (CFCS). Videos were stratified by content and source, and differences in JAMA, GQS, and CFCS scores were assessed. Multivariable linear regression was used to identify predictors of higher or lower JAMA, GQS, and CFCS scores. Statistical significance was established at P , 0.05.Results: Total number of views was 6 221 816 with a mean of 124 436.32 6 412 883.32 views per video. Physicians, academic, and medical sources had significantly higher mean JAMA scores (P ¼ 0.042). Exercise training and nonsurgical management videos had significantly higher mean CFCS scores (P ¼ 0.018). Videos by physicians (b ¼ 0.616; P ¼ 0.025) were independently associated with higher JAMA scores. Advertisements were significant predictors of worse CFCS (b ¼À3.978; P ¼ 0.030), and videos by commercial sources predicted significantly lower JAMA scores (b ¼ À1.326; P ¼ 0.006).Conclusions: While videos related to cervical fusion amassed a large viewership, they were poor in both quality and reliability. Videos by physicians were associated with higher reliability scores relative to other sources, whereas commercial sources and advertisements had significantly lower reliability and educational content scores. Currently, YouTube seems to be an unreliable source of information on cervical fusion for patients.Level of Evidence: 4. Clinical Relevance: The results of this study aid surgeons in counseling patients interested in cervical fusion, and suggest that publicly available videos regarding cervical fusion may not be an adequate tool for patient education at this time.