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Study Design: Retrospective cohort study., Objectives: To compare the incidence of complications in patients undergoing single-level and 2-level lumbar laminectomy in either the inpatient or outpatient settings., Methods: Patients who underwent single-level and 2-level lumbar laminectomy were identified in the ACS NSQIP database from the years 2006 to 2015. Independent patient variables were recorded, including demographics and preoperative health characteristics. Logistic regression was used to determine the risk of postoperative complications for both a 1- and 2-level lumbar laminectomy as well as to identify independent risk factors for a complication. Comparisons were made between 2 groups: (1) inpatient and (2) outpatient as determined by billing data., Results: A total of 18 076 single- and 2-level lumbar laminectomy cases were identified with 10 743 (59.4%) inpatient procedures and 7333 (40.6%) outpatient procedures. The incidence of any postoperative complication was significantly lower in the outpatient group than in the inpatient group among all cohorts including 1-level lumbar laminectomy (1.9% vs 6.7%), 2-level lumbar laminectomy (3.17% vs 7.38%), as well as in the combined cohort of 1- and 2-level laminectomies (2.47% vs 7.01%). Significant independent risk factors for complications after lumbar laminectomy were identified, including body mass index (BMI) >30 kg/m 2 , age ≥55 years, a functional status of partially dependent, chronic obstructive pulmonary disease (COPD), chronic steroid use, American Society of Anesthesiologists (ASA) class 3 or 4, and operative time >90 minutes., Conclusions: This study reports a lower overall complication rate in the 30-day postoperative period following 1- and 2-level lumbar laminectomy performed in an outpatient versus inpatient setting. Significant risk factors for complications included BMI >30 kg/m 2 , age ≥55 years, a functional status of partially dependent, COPD, chronic steroid use, ASA class 3 or 4, and operative time >90 minutes., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2019.)

Study Design: Retrospective cohort study., Objective: The aim of this study was to determine the differences in 30-day readmission, reoperation, and morbidity for patients undergoing multilevel anterior cervical discectomy and fusion (ACDF) or single and multilevel anterior cervical corpectomy and fusion (ACCF)., Summary of Background Data: Despite increasing rates of surgical treatment of cervical spine disease, few studies have compared outcomes by surgical technique. To the best of our knowledge, this is the only large-scale administrative database study that directly evaluates early outcomes between multilevel ACDF and single and multilevel ACCF., Methods: Patients who underwent ACDF and ACCF were identified using the NSQIP database. Multivariate regression was utilized to compare rates of readmission, reoperation, morbidity, and specific complications between surgical techniques, and to evaluate for predictors of primary outcomes., Results: We identified 15,600 patients. ACCF independently predicted (P < 0.001) greater reoperation (odds ratio [OR] = 1.876) and morbidity (OR = 1.700), but not readmission, on multivariate analysis. ACCF was also associated with greater rates of transfusion (OR = 3.273, P < 0.001) and DVT/thrombophlebitis (OR = 2.852, P = 0.001). ACCF had significantly (P < 0.001) greater operative time and length of stay. In the cohort, increasing age (P < 0.001), diabetes (P = 0.025), chronic obstructive pulmonary disease (P = 0.027), disseminated cancer (P = 0.009), and American Society of Anesthesiologists (ASA) class ≥3 (P < 0.001) predicted readmission. Age (P = 0.011), female sex (P = 0.001), heart failure (P = 0.002), ASA class ≥3 (P < 0.001), and increased creatinine (P = 0.044), white cell count (P = 0.033), and length of stay (P < 0.001) predicted reoperation. Age (P < 0.001), female sex (P = 0.002), disseminated cancer (P = 0.010), ASA class ≥3 (P < 0.001), increased white cell count (P = 0.036) and length of stay (P < 0.001), and decreased hematocrit (P < 0.001) predicted morbidity. Within ACDF, three or more levels treated compared to two levels did not predict poorer 30-day outcomes., Conclusion: Compared to multilevel ACDF, ACCF was associated with an 88% increased odds of reoperation and 70% increased odds of morbidity; readmission was similar between techniques. Older age, higher ASA class, and specific comorbidities predicted poorer 30-day outcomes. These findings can guide surgical solution given specific factors., Level of Evidence: 3.

Study Design: A retrospective cohort study., Objective: The aim of this study was to determine the difference in 30-day readmission, reoperation, and morbidity for patients undergoing either posterior or anterior lumbar interbody fusion., Summary of Background Data: Despite increasing utilization of lumbar interbody fusion to treat spinal pathology, few studies compare outcomes by surgical approach, particularly using large nationally represented cohorts., Methods: Patients who underwent lumbar interbody fusion were identified using the NSQIP database. Rates of readmission, reoperation, morbidity, and associated predictors were compared between posterior/transforaminal (PLIF/TLIF) and anterior/lateral (ALIF/LLIF) lumbar interbody fusion using multivariate regression. Bonferroni-adjusted alpha-levels were utilized whereby variables were significant if their P values were less than the alpha-level or trending if their P values were between 0.05 and the alpha-level., Results: We identified 26,336 patients. PLIF/TLIF had greater operative time (P = 0.015), transfusion (P < 0.001), UTI (P = 0.008), and stroke/CVA (P = 0.026), but lower prolonged ventilation (P < 0.001) and DVT (P = 0.002) rates than ALIF/LLIF. PLIF/TLIF independently predicted greater morbidity on multivariate analysis (odds ratio: 1.155, P = 0.0019).In both groups, experiencing a complication and, in PLIF/TLIF, ASA-class ≥3 predicted readmission (P < 0.001). Increased age trended toward readmission in ALIF/LLIF (P = 0.003); increased white cell count (P = 0.003), dyspnea (P = 0.030), and COPD (P = 0.005) trended in PLIF/TLIF. In both groups, increased hospital stay and wound/site-related complication predicted reoperation (P < 0.001). Adjunctive posterolateral fusion predicted reduced reoperation in ALIF/LLIF (P = 0.0018). ASA-class ≥3 (P = 0.016) and age (P = 0.021) trended toward reoperation in PLIF/TLIF and ALIF/LLIF, respectively. In both groups, age, hospital stay, reduced hematocrit, dyspnea, ASA-class ≥3, posterolateral fusion, and revision surgery and, in PLIF/TLIF, bleeding disorder predicted morbidity (P < 0.001). Female sex (P = 0.010), diabetes (P = 0.042), COPD (P = 0.011), and disseminated cancer (P = 0.032) trended toward morbidity in PLIF/TLIF; obesity trended in PLIF/TLIF (P = 0.0022) and ALIF/LLIF (P = 0.020)., Conclusion: PLIF/TLIF was associated with a 15.5% increased odds of morbidity; readmission and reoperation were similar between approaches. Older age, higher ASA-class, and specific comorbidities predicted poorer 30-day outcomes, while procedural-related factors predicted only morbidity. These findings can guide surgical approach given specific factors., Level of Evidence: 3.

Study Design: Preclinical animal study., Objective: Determine the in vivo effects of platelet-derived growth factor BB (PDGF-BB) delivered in a thiol-modified hyaluronic acid (TMHA) hydrogel on intervertebral disk (IVD) degeneration., Summary of Background Data: IVD degeneration is a worldwide health concern and remains without an effective treatment. Several in vitro studies have demonstrated the potential of PDGF-BB, a primary component of platelet-rich plasma, as a therapy for IVD degeneration. Our hypotheses were that treatment of injured IVDs with PDGF would inhibit degeneration and that administration of PDGF in a TMHA hydrogel would improve its efficacy., Methods: IVD degeneration was induced using the rabbit annular puncture model. Four weeks after injury, IVDs were treated with either PDGF-BB or PDGF-BB delivered within a TMHA hydrogel. The efficacy of treatment was determined using x-ray, MRI, histology, and biomechanical testing., Results: At 4 weeks after treatment, cell apoptosis and deposition of matrix containing type III collagen a1 (Col3a1) was demonstrated in both the nucleus pulposus and annulus fibrosus, while this was inhibited by PDGF. At 8 weeks after treatment, disc area and MRI indices of injured IVDs treated with PDGF were significantly higher (P < 0.05) than those treated with the TMHA alone. Similarly, degenerative scores for saline- and TMHA-treated IVDs demonstrated significantly more degeneration (P < 0.05) than PDGF-treated IVDs at 8 weeks. Biomechanical assessments found fewer indicators of degeneration in PDGF-TMHA-treated IVDs at both 4 and 8 weeks post-treatment, compared to saline-, TMHA-, and PDGF-only-treated IVDs. Both PDGF- and PDGF-TMHA-treated IVDs also demonstrated a significant increase (P < 0.05) in compressive strength to failure, compared with controls at 8 weeks post-treatment., Conclusion: The results of this study suggest that PDGF-BB significantly decreases disc degeneration and when delivered in a TMHA gel scaffold, helps prevent both apoptosis and Col3 matrix production, while maintaining disc structure and biomechanical function., Level of Evidence: NA.

Degeneration of the intervertebral disc (IVD) results in deterioration of the spinal motion segment and can lead to debilitating back pain. Given the established mitotic and anti-apoptotic effects of recombinant human platelet-derived growth factor-BB (rhPDGF-BB) in a variety of cell types we postulated that rhPDGF-BB might delay disc cell degeneration through inhibition of apoptosis. To address this hypothesis, we treated human IVD cells isolated from five independent patients with rhPDGF-BB in monolayer and 3D pellet cultures. The anti-apoptotic potential, cell proliferative capacity, morphology/pellet differentiation, and gene expression of PDGF-treated IVD cells were evaluated via flow cytometry/immunohistochemistry, MTT assays, histology, and quantitative RT-PCR, respectively. We found that rhPDGF-BB treatment significantly inhibited cell apoptosis, increased cell proliferation and matrix production, and maintained mRNA expression of critical extracellular matrix genes. This study suggests two possible mechanisms for the anti-degenerative effects of rhPDGF-BB on human IVD cells. First, PDGF treatment strongly inhibited IVD cell apoptosis in 3D cultures. Second, rhPDGF-BB acts as an anabolic agent, promoting maintenance of IVD cell phenotype in 3D culture, based on the molecular and protein expression analysis. We speculate that rhPDGF-BB may be used as a biologic treatment to target early degenerative IVD disease in the future., (© 2014 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.)