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Study Design Retrospective Cohort StudyObjectives To determine if decreased preoperative symptom duration is associated with greater clinical improvement in function and myelopathic symptoms after posterior cervical decompression and fusion (PCDF).Methods All patients over age 18 who underwent primary PCDF for cervical myelopathy or myeloradiculopathy at a single institution between 2014 and 2020 were retrospectively identified. Patient demographics, surgical characteristics, duration of symptoms, and preoperative and postoperative patient reported outcomes measures (PROMs) including modified Japanese Orthopaedic Association (mJOA), Neck Disability Index (NDI), Visual Analogue Scale (VAS) Neck, VAS Arm, and SF-12 were collected. Univariate and multivariate analyses were performed to compare change in PROMs and minimum clinically important difference achievement (%MCID) between symptom duration groups (< 6 months, 6 months–2 years, > 2 years).Results Preoperative symptom duration groups differed significantly by sex and smoking status. Patients with < 6 months of preoperative symptoms improved significantly in all PROMs. Patients with 6 months–2 years of preoperative symptoms did not improve significantly in mJOA, Physical Component Scores (PCS), or NDI. Patients with > 2 years of symptoms failed to demonstrate significant improvement in mJOA, NDI, or Mental Component Scores (MCS). Univariate analysis demonstrated significantly decreased improvement in mJOA with longer symptom durations. Increased preoperative symptom duration trended toward decreased %MCID for mJOA and MCS. Regression analysis demonstrated that preoperative symptom duration of > 2 years relative to < 6 months predicted decreased improvement in mJOA and NDI and decreased MCID achievement for mJOA and MCS.Conclusion Increased duration of preoperative symptoms (> 2 years) before undergoing PCDF was associated with decreased postoperative improvement in myelopathic symptoms.

Study Design Retrospective cohort studyObjectives The purpose of this study is to compare patient-reported outcome measures (PROMs) for patients undergoing one-to three-level lumbar fusion using robotically assisted vs freehand pedicle screw placement.Methods Patients who underwent either robotically assisted or freehand pedicle screw placement for one-to three-level lumbar fusion surgery from January 1, 2014 to August 31, 2020 at a single academic institution were identified. Propensity score matching was performed based on demographic variables. Clinical and surgical outcomes were compared between groups. Recovery Ratios (RR) and the proportion of patients achieving the minimally clinically important difference (%MCID) were calculated for Oswestry Disability Index, PCS-12, MCS-12, VAS Back, and VAS Leg at 1 year. Surgical outcomes included complication and revision rates.Results A total of 262 patients were included in the study (85 robotic and 177 freehand). No significant differences were found in ΔPROM scores, RR, or MCID between patients who underwent robotically assisted vs freehand screw placement. The rates of revision (1.70% freehand vs 1.18% robotic, P= 1.000) and complications (.57% freehand vs 1.18% robotic, P= .546) were not found to be statically different between the 2 groups. Controlling for demographic factors, procedure type (robotic vs freehand) did not emerge as a significant predictor of ΔPROM scores on multivariate linear regression analysis.Conclusions Robotically assisted pedicle screw placement did not result in significantly improved clinical or surgical outcomes compared to conventional freehand screw placement for patients undergoing one-to three-level lumbar fusion.

Study Design: Retrospective cohort study.Objective: Studies investigating the impact of interbody subsidence in ACDF suggest a correlation between subsidence and worse radiographic and patient-reported outcomes. The purpose of this study was to assess whether allograft subsidence assessed on CT is associated with worse cervical alignment.Methods: We performed a retrospective review of a prospective cohort of patients undergoing 1 to 3 level ACDF. Cervical alignment was assessed on standing radiographs performed preoperatively, less than 2 months postoperatively, and greater than 6 months postoperatively. Allograft subsidence was assessed on CT scan performed at least 6 months postoperatively. Patients with at least 1 level demonstrating greater than 4mm of cage subsidence were classified as severe subsidence. Student’s t-test was used to compare all means between groups.Results: We identified 66 patients for inclusion, including 56 patients with non-severe subsidence and 10 patients with severe subsidence. For the entire cohort, there was a significant increase in C2-7 Lordosis (p = 0.005) and Segmental Lordosis (p < 0.00 001) from preoperative to early postoperative. On comparison of severely and non-severely subsided levels, severely subsided levels demonstrated a significantly greater loss of segmental lordosis from early to mid-term follow-up than non-severely subsided levels (-4.89 versus -2.59 degrees, p < 0.0001), manifesting as a significantly lower segmental lordosis at >6 months postoperative (0.54 versus 3.82 degrees, p < 0.00 001). There were no significant differences in global cervical alignment parameters between patients with severe and non-severe subsidence.Conclusions: Severe subsidence is associated with a significant increase in loss of segmental lordosis, but has minimal effect on global cervical alignment parameters.

Study Design: Retrospective database review.Objectives: The incidence and risk factors for surgical delay of multilevel spine fusion for adult spinal deformity (ASD), and the complications corresponding therewith, remain unknown. The objectives of this study are to assess the incidence and risk factors for unexpected delay of elective multilevel spinal fusions on the date of surgery as well as the postoperative complications associated with these delays.Methods: We conducted a retrospective review of the ACS-NSQIP database on patients undergoing elective spinal instrumentation of greater than 7 levels for ASD between the years 2005 and 2015. Preoperative risk factors for delay and postoperative complications were compared between the cohorts of patients with and without surgical delays.Results: Multivariate analysis of 1570 (15.6%) patients identified advanced age, male sex, American Society of Anesthesiologists (ASA) Class 4, and history of smoking as independent risk factors for delay. Patients experiencing surgical delay demonstrated longer operative times, increased intraoperative bleeding, longer hospitalizations, and significantly higher rates of postoperative complications. Patients experiencing delay demonstrated an almost 7-fold increase in mortality rate (3.4% vs 0.5%, P< .001).Conclusions: Delays in elective surgical care for spinal deformity are negatively related to patient outcomes. Advanced age, male sex, increased ASA class, and a history of smoking cigarettes place patients at risk for surgical delay of multilevel spinal fusion. Patients experiencing surgical delay are at higher risk for postoperative complications, including a 7-fold increase in mortality. These findings suggest that ASD surgery should be postponed in patients experiencing a delay, until modifiable risk factors can be medically optimized, and perhaps postponed indefinitely in those with nonmodifiable risk factors.

Study Design: Retrospective cohort study.Objective: The goal of this study was to determine whether the absolute size (mm2), relative size (% canal compromise), or location of a single-level, lumbar disc herniation (LDH) on axial and sagittal cuts of magnetic resonance imaging (MRI) were predictive of eventual surgical intervention.Methods: MRIs of 89 patients were reviewed, and patients were split into groups based on type of management received (34 nonoperative vs 55 microdiscectomy). Radiographic characteristics—including size of disc herniation (mm2), size of spinal canal (mm2), location of herniation on axial (central, paracentral, foraminal) and sagittal (disc level, suprapedicle, pedicle, infrapedicle) planes, and type of herniation (bulge, protrusion, extrusion, sequestration)—were measured by 2 independent, orthopedic spine fellows and compared between groups via univariate and multivariate analyses.Results: The operative group showed a significantly higher percentage of canal compromise (39.5% vs 31.1%, P= .001) compared to the nonoperative group. Multiple logistic regression analysis showed higher odds of eventual operative intervention for a disc protrusion (odds ratio [OR] 6.30 [1.99, 19.86], P= .002) or disc extrusion (OR 11.5 [1.63, 81.2], P= .014) for Rater 1 and a higher odds of eventual surgical management for a paracentral location for both Rater 1 and Rater 2 (OR = 3.39 [1.25, 9.22], P= .017, and OR = 5.46 [1.77, 16.8], P= .003, respectively).Conclusions: Disc herniations in a paracentral location were more likely to undergo operative treatment than those more centrally located, on axial MRI views.

Study Design: Retrospective cohort study.Objective: The goal of this study was to determine how smoking status influences patient-reported outcome measurements (PROMs) in patients undergoing lumbar decompression surgery.Methods: Patients undergoing lumbar decompression between 1 to 3 levels at a single-center, academic hospital were retrospectively identified. Patients <18 years old, and those undergoing surgery for infection, trauma, tumor, or revision, with less than 12 months of follow-up were excluded. Patients were divided into 3 groups: (1) never smokers (NSs); (2) current smokers (CSs); and (3) former smokers (FSs). PROMs analyzed included the Physical Component Score and Mental Component Score of the Short Form-12 Health Survey, the Oswestry Disability Index, and Visual Analogue Scale Back and Leg pain scores. One-way ANOVA was used to compare preoperative and postoperative scores between smoking groups, and multiple linear regression analysis was performed to determine whether smoking status predicted change in each outcome score, controlling for factors such as age, sex, body mass index, and other clinical variables. A Pvalue <.05 was considered to be significant.Results: A total of 195 patients were included in the final cohort, with 121 (62.1%) patients in the NS group, 22 (11.3%) in the CS group, and 52 (26.6%) in the FS group. There were no significant differences between groups at baseline or postoperatively. Smoking status was also not a significant predictor of change in any outcome scores over time on multivariate analysis.Conclusion: These results suggest that smoking status does not significantly affect short-term complications or outcomes in patients undergoing lumbar decompression surgery.

Study design: Retrospective comparative study.Objective: Whereas smoking has been shown to affect the fusion rates for patients undergoing an anterior cervical discectomy and fusion (ACDF), the relationship between smoking and health-related quality of life outcome measurements after an ACDF is less clear. The purpose of this study was to evaluate whether smoking negatively affects patient outcomes after an ACDF for cervical degenerative pathology.Methods: Patients with tumor, trauma, infection, and previous cervical spine surgery and those with less than a year of follow-up were excluded. Smoking status was assessed by self-reported smoking history. Patient outcomes, including Neck Disability Index, Short Form 12 Mental Component Score, Short Form 12 Physical Component Score (PCS-12), Visual Analogue Scale (VAS) arm pain, VAS neck pain, and pseudarthrosis rates were evaluated. Outcomes were compared between smoking groups using multiple linear and logistic regression, controlling for age, sex, and body mass index (BMI), among other factors. A Pvalue <.05 was considered significant.Results: A total of 264 patients were included, with a mean follow-up of 19.8 months, age of 53.1 years, and BMI of 29.6 kg/m2. There were 43 current, 69 former, and 152 nonsmokers in the cohort. At baseline, nonsmokers had higher PCS-12 scores than current smokers (P= .010), lower VAS neck pain than current (P= .035) and former (P= .014) smokers, as well as lower VAS arm pain than former smokers (P= .006). Postoperatively, nonsmokers had higher PCS-12 scores than both current (P= .030) and former smokers (P= .035). Smoking status was not a significant predictor of change in patient outcome in multivariate analysis.Conclusions: Whereas nonsmokers had higher function and lower pain than former or current smokers preoperatively, smoking status overall was not found to be an independent predictor of outcome scores after ACDF. This supports the notion that smoking status alone should not deter patients from undergoing ACDF for cervical degenerative pathology.

Study Design: Retrospective, single institution, multisurgeon case control series.Objective: To determine whether there are differences in reoperation rates or outcomes for patients undergoing 2-level posterolateral fusion (PLF) augmented by a transforaminal lumbar interbody fusion (TLIF) at only one of the levels or at both.Methods: A total of 416 patients were identified who underwent 2-level PLF with a TLIF at either one of those levels (n = 183) or at both (n = 233) with greater than 1-year follow-up. Demographic, surgical, radiographic, and clinical data was reviewed for each patient. These included age, sex, race, body mass index, smoking status, Charleston Comorbidity Index, operative time, estimated blood loss, length of stay, and patient-reported outcome measures.Results: Each cohort underwent 24 reoperations. Although the number of overall reoperations was not significantly different (P> .05), among the reoperation types, there were significantly more reoperations for adjacent segment disease in the 2-level group compared to the 1-level group (19 vs 12, P= .04). There was no difference in reoperation for pseudarthrosis between the groups (P> .05). Although both groups experienced significant improvements in Oswestry Disability Index (P< .001) and Short Form–12 health questionnaire (P< .001), there were no differences between improvements for 1- versus 2-level cohorts.Conclusions: For patients undergoing 2-level PLF in the setting of a TLIF, using a TLIF at one versus both levels does not seem to influence reoperation rates or outcomes. However, reoperation rates for adjacent segment disease are increased in the setting of a 2-level PLF augmented by a 2-level TLIF.

Study Design: Retrospective cohort reviewObjectives: Cervical pseudarthrosis is a frequent cause of need for revision anterior cervical discectomy and fusion (ACDF) and may lead to worse patient-reported outcomes. The effect of proton pump inhibitors on cervical fusion rates are unknown. The purpose of this study was to determine if patients taking PPIs have higher rates of nonunion after ACDF.Methods: A retrospective cohort review was performed to compare patients who were taking PPIs preoperatively with those not taking PPIs prior to ACDF. Patients younger than 18 years of age, those with less than 1-year follow-up, and those undergoing surgery for trauma, tumor, infection, or revision were excluded. The rates of clinically diagnosed pseudarthrosis and radiographic pseudarthrosis were compared between PPI groups. Patient outcomes, pseudarthrosis rates, and revision rates were compared between PPI groups using either multiple linear or logistic regression analysis, controlling for demographic and operative variables.Results: Out of 264 patients, 58 patients were in the PPI group and 206 were in the non-PPI group. A total of 23 (8.71%) patients were clinically diagnosed with pseudarthrosis with a significant difference between PPI and non-PPI groups (P= .009). Using multiple linear regression, PPI use was not found to significantly affect any patient-reported outcome measure. However, based on logistic regression, PPI use was found to increase the odds of clinically diagnosed pseudarthrosis (odds ratio 3.552, P= .014). Additionally, clinically diagnosed pseudarthrosis negatively influenced improvement in PCS-12 scores (P= .022).Conclusions: PPI use was found to be a significant predictor of clinically diagnosed pseudarthrosis following ACDF surgery. Furthermore, clinically diagnosed pseudarthrosis negatively influenced improvement in PCS-12 scores.

The most popular approach to treating symptomatic cervical disk disease is anterior cervical discectomy and fusion. Although this procedure has significant long-term clinical success, it is associated with progressive adjacent segment degeneration with an annual incidence of ∼3%. Total disk arthroplasty was designed as an alternative to fusion that could preserve segmental motion at the operative level and potentially delay or prevent adjacent-level breakdown. The etiology of adjacent segment pathology (ASP) is multifactorial, and it is likely that most cases of ASP are unavoidable. When attempting to surgically prevent ASP, it is important to consider nonfusion alternatives, be judicious in one’s level selection, and attempt to restore sagittal alignment. When ASP becomes a clinical problem, it is important to have an algorithm for how best to treat it.

The prestige of publication has been based on traditional citation metrics, most commonly journal impact factor. However, the Internet has radically changed the speed, flow, and sharing of medical information. Furthermore, the explosion of social media, along with development of popular professional and scientific websites and blogs, has led to the need for alternative metrics, known as altmetrics, to quantify the wider impact of research. We explore the evolution of current research impact metrics and examine the evolving role of altmetrics in measuring the wider impact of research. We suggest that altmetrics used in research evaluation should be part of an informed peer-review process such as traditional metrics. Moreover, results based on altmetrics must not lead to direct decision making about research, but instead, should be used to assist experts in making decisions. Finally, traditional and alternative metrics should complement, not replace, each other in the peer-review process.

Traditionally, the success of a researcher has been judged by the number of publications he or she has published in peer-review, indexed, high impact journals. However, to quantify the impact of research in the wider scientific community, a number of traditional metrics have been used, including Impact Factor, SCImago Journal Rank, Eigenfactor Score, and Article Influence Score. This article attempts to provide a broad overview of the main traditional impact metrics that have been used to assess scholarly output and research impact. We determine that there is no perfect all-encompassing metric to measure research impact, and, in the modern era, no single traditional metric is capable of accommodating all facets of research impact. Academics and researchers should be aware of the advantages and limitations of traditional metrics and should be judicious when selecting any metrics for an objective assessment of scholarly output and research impact.