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Study Design: Retrospective cohort study. Objective: The purpose of the study was to compare early complication, morbidity and mortality risks associated with fusion surgery crossing the cervico-thoracic junction in patients aged over 80 years undergoing combined anterior and posterior approach versus a posterior-only approach. Methods: We retrospectively identified octogenarian patients with myelopathy who underwent fusion crossing the cervico-thoracic junction. Patient demographics, Nurick score, surgical characteristics, complications, hospital course, early outcome and 90-day mortality were collected. Comorbidities were classified using the age-adjusted Charlson Comorbidity Index (AACCI). Radiographic measurements for deformity correction included the C2-C7 sagittal Cobb angle, C2-7 sagittal vertical axis and T1 slope pre- and postoperatively. Results: Out of 8,521 surgically treated patients, 12 octogenarian patients had a combined anterior and posterior approach (AP group) and 14 were treated from posterior-only (P group). Mean age was 81.4 ± 1.2 and 82.5 ± 2.7 years, respectively. There was no significant difference in Nurick scores between the groups ( P > 0.05). The major complication risk in the AP group was significantly higher, requiring PEG tube placement due to severe dysphagia in 4 patients (33%) compared to none in the P group. A greater improvement in cervical lordosis could be achieved through a combined approach. The 90-day mortality risk was 8% for the AP group and 0% for the P group. Conclusions: A combined anterior and posterior approach is associated with a significantly higher major complication rate and can result in severe dysphagia requiring PEG tube placement in one-third of patients over 80 years of age.

Study design: Case-Control Study. Objective: The purpose of this retrospective study is to evaluate risk factors for developing a postoperative ileus after posterior spine surgery. Methods: Patient charts, including radiographs were evaluated retrospectively. Diagnosis of an ileus was confirmed radiographically by a CT scan in all cases. The control group was retrieved by selecting a random sample of patients undergoing posterior spine surgery who did not develop bowel dysfunction postoperatively. Results: A total of 40 patients had a postoperative ileus. The control group consisted of 80 patients. Both groups did not differ significantly in age, gender, BMI, tobacco use, comorbidities or status of previous abdominal surgery. Significant differences between the 2 groups was the length of stay (5.9 vs. 11.2; p = 0.001), surgery in the lumbar spine (47.5% vs. 87.5%; p < 0.001) and major spine surgery involving > 3 levels (35.0% vs. 57.5%; p = 0.019). Patients who suffered from an ileus were more likely to be treated in ICU (23.8% vs. 37.5%; p = 0.115), being re-admitted (0.0% vs 5.0%; p = 0.044) and having a delayed discharge (32.5% vs. 57.5%; p = 0.009). Multivariable analysis demonstrated that lumbar spine surgery compared to thoracic and/or cervical spine surgery (p = 0.00, OR 8.7 CI 2.9-25.4) and major spine surgery involving > 3 levels (p = 0.012; OR 3.0, CI 1.3-7.2) are associated with developing an ileus postoperatively. Conclusion: Surgeries of the lumbar spine as well as those involving > 3 levels are associated with developing a postoperative ileus. Further studies are needed to expand on possible risk factors and to better understand the mechanism underlying postoperative ileus in spine surgery patients.

Our health care system is an evidenced-based quality-centric environment. Pursuit of quality is a process that encompasses knowledge development and care advancements through collaboration and expertise. Depicted here is the foundational knowledge, process, and contributions that hallmark successful clinical quality programs. Beginning with methodology, followed by process and form, we create the foundational knowledge and exemplars demonstrating framework and continuum of process in pursuit and attainment of successful clinical quality and care development for patients. Although our protocol has been devised for complex spine care, this could be implemented across all health care specialties to provide individualized and high-quality care for all current and future patients, all while creating a culture of accountability for physicians.

Study Design: Retrospective cohort study. Objective: Anterior approaches are often used during lumbar interbody fusion procedures. Visceral injuries (bowel injuries) are rare but represent a primary risk during anterior approaches to the lumbar spine. Left untreated, these injuries can result in significant complications. The aim of this study was to investigate the presentation and management of bowel injury cases following anterior approaches to the lumbar spine to raise the surgeon’s awareness of this rare complication. Methods: All direct anterior, oblique anterior, and transpsoas lumbar interbody fusion surgeries performed at our institution between 2012 and 2016 were analyzed retrospectively. Charts were screened for cases requiring return to the operating room owing to a suspected bowel injury and details of the case were extracted for illustrative purposes. Results: A total of 775 anterior lumbar surgeries were conducted at a single tertiary care institution between July 2012 and June 2017. A total of 590 transpsoas lumbar interbody fusion (TPIF) surgeries were performed. Four patients, each having undergone TPIF, were suspected of bowel injury and underwent an exploratory laparotomy. At surgery, 3 patients were confirmed to have a bowel injury, giving a procedure-specific incidence of 0.51% and overall incidence of 0.39%. Among the 3 confirmed bowel injury cases, average delay between surgery and visceral injury diagnosis was 4.7 days (range 3-7 days). Conclusions: We noted abdominal pain, distention, and fever as the most common findings in the setting of a visceral injury. A high index of suspicion and computed tomography imaging remain critical for identifying postoperative bowel injuries.

Parametric and nonparametric are 2 broad classifications of statistical procedures. Parametric tests are based on assumptions about the distribution of the underlying population from which the sample was taken. The most common parametric assumption is that data is approximately normally distributed. Nonparametric tests do not rely on assumptions about the shape or parameters of the underlying population distribution. Use nonparametric tests for categorical data or continuous data that is not normally distributed. The decision on which statistical test to select for analysis can be aided by using a decision tree such as the one given in the text above. Rethink how you approach evaluating a study in the future. Consider looking at the data first and reviewing its characteristics, the shape and the type of data gathered. And then see what the authors chose to do with their data. Assessing research in this manner will assist in determining the validity of the investigators’ methods and subsequent results reporting.