Surgical site infections (SSIs) are a potentially devastating complication of spine surgery. SSIs are defined by the Centers for Disease Control and Prevention as occurring within 30 days of surgery or within 12 months of placement of foreign bodies, such as spinal instrumentation. SSIs are commonly categorized by the depth of surgical tissue involvement (ie, superficial, deep incisional, or organ and surrounding space). Postoperative infections result in increased costs and postoperative morbidity. Because continued research has improved the evaluation and management of spinal infections, spine surgeons must be aware of these modalities. The controversies in evaluation and management of SSIs in spine surgery will be reviewed.

Retro-odontoid pseudotumors are noninflammatory masses formed posterior to the odontoid process. Because of their anatomy, the optimal surgical approach for resecting pseudotumors is controversial. Conventionally, 3 approaches are used: the anterior transoral approach, the lateral approach, and the posterior extradural approach; however, each approach has its limitations. The posterior extradural approach is the most common; however, it remains challenging due to severe epidural veins. Although regression of pseudotumors after fusion surgery has been reported, direct decompression and a pathologic diagnosis are ideal when the pseudotumor is large. We therefore developed a new microscopic surgical technique; transdural resection. After C1 laminectomy, the dorsal and ventral dura was incised while preserving the arachnoid. Removal of the pseudotumor was performed and both of the dura were repaired. The patient's clinical symptoms subsequently improved and the pathologic findings showed degenerative fibrocartilaginous tissue. In addition, no neurological deterioration, central spinal fluid leakage, or arachnoiditis was observed. Currently, the usefulness of the transdural approach has been reported for cervical and thoracic disk herniation. According to our results, the transdural approach is recommended for resection of retro-odontoid pseudotumors because it enables direct decompression of the spinal cord and a pathologic diagnosis.

Over the last 5 years, there has been a growing trend toward consolidation in the health care field. As reimbursement moves from a fee-for-service model to a value-based model, there will be continued pressure on physicians to either be a hospital employee or to be in a large multidisciplinary practice. This is largely due to the Accountable Care Act, which directs payers to utilize population-based cost analyses, rather than an individual patient-based analysis. To succeed in this environment, practices will have to break down traditional organizational barriers to create evidence-based algorithms for the treatment of individual diagnoses from the initial onset of symptoms until the resolution of symptoms.

Assuming data follow a normal distribution is essential for many common statistical tests. However, what are normal data and when can we assume that a data set follows this distribution? What can be done to analyze non-normal data?

Postoperative epidural hematomas are rare complications following lumbar spine surgery, but if they are not quickly identified and treated they can lead to permanent neurological deficits. Epidural hematomas occur in approximately 0.10%-0.24% of all spine surgeries, and despite the fact that multiple large studies have been performed attempting to identify risk factors for this complication, there is still significant debate about the effect of subfascial drains, postoperative anticoagulation, and antiplatelet medication on the incidence of postoperative hematoma. The purpose of this manuscript is to review the epidemiology, etiology, diagnosis, and treatment of patients who develop a postoperative lumbar epidural hematoma.

Significant changes are occurring in the health care field, and spine surgeons must have an understanding of business strategy if they are going to adapt to the new health care environment. Spine surgeons will be required to demonstrate how their service provides a unique value to their patients or else the patients will obtain care from competitors. Classic methods for demonstrating value such as academic prestige and superior clinical outcomes may no longer be sufficient in the evolving health care field, and surgeons will need to demonstrate a comprehensive and cost-effective treatment algorithm for a diagnosis. This article will discuss the basics of business strategy for the spine surgeon, and ways in which the surgeon may demonstrate value to their patients.

Regression models are commonly used in spine research today, and they can be used to explain or predict an outcome. A regression model can indicate the relative impact of each variable on the expected outcome, so when the model has been developed, it can be used to predict the outcome for a hypothetical patient.

As the US health care system transitions toward a value-based system, providers and health care organizations will have to closely scrutinize their current processes of care. To do this, a value chain analysis can be performed to ensure that only the most efficient steps are followed in patient care. Ultimately this will produce a higher quality or equal quality product for less cost by eliminating wasteful steps along the way.

Venous thromboembolic embolism (VTE) is a potentially serious and life-threatening complication in spine surgery. However, VTE incidence and prophylaxis in spine surgery remains controversial. Current recommendations for VTE prophylaxis address "spine surgery" as a single broad category and mainly consider patient factors when determining risk. We performed a literature review to determine the varying VTE and bleeding risks within spine surgery to develop an individualized prophylactic algorithm. Our review suggests that the current guidelines on VTE prophylaxis for spine surgery from NASS and ACCP are suboptimal. Consideration of (1) patient-related VTE risks, (2) procedure-related VTE risks, and (3) the risk of neurological compromise from bleeding complications will more appropriately balance safety and effectiveness when choosing a VTE prophylaxis method. To better individualize VTE prophylaxis, we have developed the VTE Prophylaxis Risk/Benefit Score that considers this currently available best evidence to arrive at a recommendation for the most appropriate form of VTE prophylaxis. This algorithm informs the surgeon to help make a more nuanced and individualized determination of prophylaxis.