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Study design Case report (level V evidence). Objective We report a case of a 33-year-old man with Marfan syndrome that visited our clinic for left knee pain and stiffness. Radiographs of the left knee and lumbar spine demonstrated a spinal rod in the posterolateral left knee and its origin being a broken rod from his previous unilateral spinal fusion 17 years prior. Summary of background data Spinal arthrodesis is a common treatment modality for a wide range of spinal pathologies including infection, trauma, congenital and developmental deformities, and degenerative conditions. A rare complication that may arise from said procedure is implant migration, most often a result of pseudoarthrosis. Methods Description of the case report. Results Patient was taken to the operating room 2 weeks later for an uneventful removal of the implant and immediate improvement with pain and range of motion. Conclusion Spinal implant migration is a rare complication most often due to implant failure from pseudoarthrosis. In the case presented, this phenomenon was likely attributed to the use of unilateral instrumentation coupled with Marfan syndrome, shown to lead to insufficient implant stability and poorer fusion rates, respectively.Level of Evidence: 5.

STUDY DESIGN Retrospective study of prospectively collected data. OBJECTIVE To perform a multiinstitutional assessment on the incidence and risk factors for unplanned readmissions following elective posterior lumbar fusion (PLF) surgery. SUMMARY OF BACKGROUND DATA Understanding what may drive rehospitalizations is a necessary step toward higher quality care. Identifying risk factors for unplanned readmission is especially important for elective PLF, which is a common procedure that is known to be associated with significant adverse events. METHODS Adult patients undergoing PLF were identified using current procedure terminology (CPT) from the American College of Surgeons National Surgical Quality Improvement Program. Both descriptive and comparative statistics were performed for patient characteristics, clinical factors, and postoperative complications. Subsequently, a step-wise multivariate logistic regression was employed. RESULTS Of the 2301 patients who met inclusion criteria for this study, 117 were unplanned readmissions (5.1%). These occurred at a mean of 15.9 days (range: 3-30 days) after surgery. The risk-adjusted analysis revealed that bleeding disorder (odds ratio, OR = 2.8, confidence intervals, CI = 1.0-7.6, P = 0.043), insulin dependent diabetes (OR = 2.5, CI = 1.4-4.4, P = 0.004), and total length of stay > 5 days (OR = 1.8, CI = 1.2-2.8, P = 0.009) were independent predictors for unplanned readmission. Significant postoperative complications included wound complications (OR = 27.6, CI = 13.9-54.8, P

STUDY DESIGN Retrospective study of prospectively collected data. OBJECTIVE To explore interdatabase reliability between National Inpatient Sample (NIS) and National Surgical Quality Improvement Program (NSQIP) for anterior cervical discectomy and fusion (ACDF) in data collection and its impact on subsequent statistical analyses. SUMMARY OF BACKGROUND DATA Clinical studies in orthopedics using national databases are ubiquitous, but analytical differences across databases are largely unexplored. METHODS A retrospective cohort study of patients undergoing ACDF surgery was performed in NIS and NSQIP. Key demographic variables, comorbidities, intraoperative characteristics, and postoperative complications were analyzed via bivariate and multivariate analyses. RESULTS A total of 112,162 patients were identified from NIS and 10,617 from NSQIP. Bivariate analysis revealed small, but significant, differences between patient demographics, whereas patient comorbidities and ACDF intraoperative variables were largely much more distinct across the two databases. Multivariate analysis identified independent risk factors between NIS and NSQIP for mortality, cardiac complications, and postoperative sepsis, some of which were identified in both but most of which were unique to one database. Identification of independent risk factors from both databases specifically highlights their greater validity and importance in stratifying patient risks. In addition, NSQIP was found to be a more accurate predictor for complications based on the average areas under the receiver-operating curve (CNSQIP = 0.83 vs. CNIS = 0.81) across the multivariate models. Complication rate analysis between inpatient and outpatient settings in NSQIP showed the importance of at least 30-day patient follow up, which was devoid in NIS data tabulation and further marked its weakness compared with NSQIP. CONCLUSION Despite having largely similar patient demographics, this study highlights critical risk factors for ACDF and demonstrates how different patient profiles can be across NIS and NSQIP, the impact of such differences on identification of independent risk factors, and how NSQIP is ultimately better suited for adverse-event studies. LEVEL OF EVIDENCE 3.

Study design Retrospective study of prospectively collected data. Objective To determine if the modified Frailty Index (mFI) could be used to predict postoperative complications in patients undergoing surgery for adult spinal deformity (ASD). Summary of background data Surgery for patients with ASD is associated with high complication rates and significant concerns present during risk stratification with older patients. The mFI is an evaluation tool to describe the frailness of an individual and how their preoperative status may impact postoperative survival and outcomes. Using a large nationwide database, we assessed the utility of this instrument in patients undergoing surgery for ASD. Methods The American College of Surgeons National Surgical Quality Improvement Program is a large multicenter clinical registry that prospectively collects preoperative variables, patient demographics, operative factors, and 30-day postoperative morbidity and mortality outcomes from about 400 hospitals nationwide. Current Procedural Terminology codes were used to query the database for adults who underwent fusion for spinal deformity. The previously described mFI was calculated based on the number of positive factors and univariate and multivariate logistic regression analysis were used to analyze the risk factors associated with mortality. Results Overall, 1001 patients were identified and the mean mFI score was 0.09 (range: 0-0.545). Increasing mFI score was associated with higher complication, reoperation, and mortality rates (P 60 years obesity class III, mFI was a superior predictor of several postoperative complications and reoperation. Conclusion Frailty was an independent predictor of postoperative complications, mortality, and reoperation in patients undergoing surgery for ASD. Preoperative assessment of the mFI in this patient population can be utilized to improve current risk models. Level of evidence 3.

A retrospective study of prospectively collected data.The aim of this study was to determine whether patients undergoing spinal deformity surgery with resident involvement are at an increased risk of morbidity.Resident involvement has been investigated in other orthopedic procedures but has not been studied in adult spinal deformity surgery.The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) is a large multicenter clinical registry that prospectively collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from about 400 hospitals nationwide. Current procedural terminology (CPT) codes were used to query the database for adults who underwent fusion for spinal deformity between 2005 and 2012. Patients were separated into propensity score matched groups of those with and without resident involvement. Univariate analysis and multivariate logistic regression were used to analyze the effect of resident involvement on the incidence of postoperative morbidity and other surgical outcomes.Resident involvement was an independent predictor of overall morbidity [odds ratio (OR) 2.2, P 0.0001], wound complication (OR 2.5, P = 0.0252), intra-/postoperative transfusion (OR 2.3, P 0.0001), and length of stay 5 days (OR 2.0, P 0.0001). However, resident involvement was not an independent predictor for other complications, such as mortality.Resident participation was associated with significantly longer operative times. As a result, higher rate of certain morbidity, but not mortality, was found, specifically for complications that have been previously associated with long operative duration.3.

STUDY DESIGN A retrospective cohort analysis of prospectively collected data. OBJECTIVE The aim of this study was to analyze morbidity and mortality in adult patients undergoing transoral approach using a large national database. SUMMARY OF BACKGROUND DATA The transoral approach to the anterior skull base and atlanto-axial cervical spine provides a direct corridor to the lower clivus, C1, C2, and occasionally C3. Due to the rarity of this approach and the unfamiliar anatomy, there is potential for significant morbidity and mortality. METHODS Adult patients undergoing transoral approach to the cervical spine from 2008 to 2012 were identified by the Current Procedural Terminology (CPT) code 22548 in the ACS NSQIP database. Cases with missing preoperative information were excluded. Univariate and multivariate analyses were performed to assess associated morbidity and mortality. RESULTS One hundred twenty-six patients underwent cervical spine and clival surgery via the transoral approach. There were a total of 27 (21.4%) postoperative complications with three (2.4%) mortalities. On multivariate analysis, there was an increased risk of complications with operative time >4 hours [odds ratio (OR) 7.8, 95% confidence interval (95% CI) 1.8-33.1, P = 0.0054] and total length of stay >5 days (OR 7.5, 95% CI 2.4-23.4, P = 0.0006). CONCLUSION The transoral approach carries significant risks of morbidity and mortality. Maintaining operative time

Study design A retrospective subgroup analysis was performed on surgically treated patients from the lumbar spinal stenosis (SpS) arm of the Spine Patient Outcomes Research Trial (SPORT), randomized, and observational cohorts. Objective To identify risk factors for reoperation in patients treated surgically for SpS and compare outcomes between patients who underwent reoperation with those who did not. Summary of background data SpS is one of the most common indications for surgery in the elderly; however, few long-term studies have identified risk factors for reoperation. Methods A post-hoc subgroup analysis was performed on patients from the SpS arm of the SPORT, randomized and observational cohorts. Baseline characteristics were analyzed between reoperation and no-reoperation groups using univariate and multivariate analysis on data 8 years postoperation. Results Of the 417 study patients, 88% underwent decompression only, 5% noninstrumented fusion, and 6% instrumented fusion. At the 8-year follow-up, the reoperation rate was 18%; 52% of reoperations were for recurrent stenosis or progressive spondylolisthesis, 25% for complication or other reason, and 16% for new condition. Of patients who underwent a reoperation, 42% did so within 2 years, 70% within 4 years, and 84% within 6 years. Patients who underwent reoperation were less likely to have presented with any neurological deficit (43% reop vs. 57% no reop, P = 0.04). Patients improved less at follow-up in the reoperation group (P Conclusion In patients undergoing surgical treatment for SpS, the reoperation rate at 8-year follow-up was 18%. Patients with a reoperation were less likely to have a baseline neurological deficit. Patients who did not undergo reoperation had better patient reported outcomes at 8-year follow-up compared with those who had repeat surgery. Level of evidence 2.

Retrospective study of prospectively collected data.To determine if the modified Frailty Index (mFI) could be used to predict postoperative complications in patients undergoing surgery for adult spinal deformity (ASD).Surgery for patients with ASD is associated with high complication rates and significant concerns present during risk stratification with older patients. The mFI is an evaluation tool to describe the frailness of an individual and how their preoperative status may impact postoperative survival and outcomes. Using a large nationwide database, we assessed the utility of this instrument in patients undergoing surgery for ASD.The American College of Surgeons National Surgical Quality Improvement Program is a large multicenter clinical registry that prospectively collects preoperative variables, patient demographics, operative factors, and 30-day postoperative morbidity and mortality outcomes from about 400 hospitals nationwide. Current Procedural Terminology codes were used to query the database for adults who underwent fusion for spinal deformity. The previously described mFI was calculated based on the number of positive factors and univariate and multivariate logistic regression analysis were used to analyze the risk factors associated with mortality.Overall, 1001 patients were identified and the mean mFI score was 0.09 (range: 0-0.545). Increasing mFI score was associated with higher complication, reoperation, and mortality rates (P 0.05). mFI of 0.09 and 0.18 was an independent predictor of any complication, mortality, requiring a blood transfusion, pulmonary embolism/deep vein thrombosis, and reoperation (all P 0.05). In comparison with age60 years obesity class III, mFI was a superior predictor of several postoperative complications and reoperation.Frailty was an independent predictor of postoperative complications, mortality, and reoperation in patients undergoing surgery for ASD. Preoperative assessment of the mFI in this patient population can be utilized to improve current risk models.3.

Retrospective study of prospectively collected data.To investigate the applicability of the modified frailty index (mFI) as a predictor of adverse postoperative events in patients undergoing anterior cervical discectomy and fusion (ACDF) or posterior cervical fusion (PCF).Prior studies have investigated the mFI and shown it as an independent predictor of adverse postoperative outcomes across multiple surgical specialties. However, this topic has not still been studied in patients undergoing cervical fusion or in spinal surgery.The National Surgical Quality Improvement Program is a multicenter clinical registry that prospectively collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from about 400 hospitals nationwide. Current Procedural Terminology codes were used to query the database for adults who underwent elective ACDF and PCF between 2005 and 2012. The mFI was calculated for each patient. Univariate analysis and multivariate logistic regression were used to analyze the mFI as a predictor for postoperative complications.For ACDF group, Clavien-Dindo grade IV complications rate increased from 0.8% to 9.0% as mFI increased from 0 to ≥0.27, and mFI = 0.27 was found to be an independent predictor of Clavien-Dindo grade IV complications (odds ratio, OR, = 4.67, 95% confidence interval, CI, = 2.27-9.62, P 0.001). For PCF groups, Clavien-Dindo grade IV complications rate increased from 0.7% to 20.0% as mFI increased from 0 to ≥0.36, and mFI ≥ 0.36 was identified as an independent predictor of Clavien-Dindo grade IV complications (OR = 41.26, 95% CI = 6.62-257.15, P 0.001).The mFI was shown to be an independent predictor of Clavien-Dindo grade IV complications in patients undergoing ACDF or PCF. The mFI itself may be used to stratify risks in patients undergoing cervical fusion, or, the mFI scheme could be used as a platform upon which more efficient risk stratification could be done with addition of other variables.4.

Retrospective study of prospectively collected data.To perform a multiinstitutional assessment on the incidence and risk factors for unplanned readmissions following elective posterior lumbar fusion (PLF) surgery.Understanding what may drive rehospitalizations is a necessary step toward higher quality care. Identifying risk factors for unplanned readmission is especially important for elective PLF, which is a common procedure that is known to be associated with significant adverse events.Adult patients undergoing PLF were identified using current procedure terminology (CPT) from the American College of Surgeons National Surgical Quality Improvement Program. Both descriptive and comparative statistics were performed for patient characteristics, clinical factors, and postoperative complications. Subsequently, a step-wise multivariate logistic regression was employed.Of the 2301 patients who met inclusion criteria for this study, 117 were unplanned readmissions (5.1%). These occurred at a mean of 15.9 days (range: 3-30 days) after surgery. The risk-adjusted analysis revealed that bleeding disorder (odds ratio, OR = 2.8, confidence intervals, CI = 1.0-7.6, P = 0.043), insulin dependent diabetes (OR = 2.5, CI = 1.4-4.4, P = 0.004), and total length of stay5 days (OR = 1.8, CI = 1.2-2.8, P = 0.009) were independent predictors for unplanned readmission. Significant postoperative complications included wound complications (OR = 27.6, CI = 13.9-54.8, P 0.0001), pulmonary embolism and/or deep vein thrombosis/thrombophlebitis (OR = 11.9, CI = 5.0-28.5, P 0.0001), sepsis (OR = 8.5, CI = 2.3-32.1, P = 0.002), and urinary tract infections (OR = 2.4, CI = 0.9-6.9, P = 0.094).The unplanned readmission rate for patients undergoing PLF was low, but this study's findings of potentially modifiable risk factors suggest that substantial improvement with this quality metric is possible.N/A.

Retrospective study of prospectively collected data.To determine if postoperative morbidity for patients undergoing spinal deformity surgery varies by sex.Influence of sex has been investigated in other surgical procedures but has not yet been studied in adult spinal deformity surgery.The American College of Surgeons National Surgical Quality Improvement Program is a large multicenter clinical registry that prospectively collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from about 400 hospitals nationwide. Current Procedural Terminology codes were used to query the database for adults who underwent fusion for spinal deformity. Patients were separated into groups of male and female sex. Univariate analysis and multivariate logistic regression were used to analyze the effect of sex on the incidence of postoperative morbidity and mortality.Female sex was found to be a predictor of any complication[odds ratio (OR): 1.4, 95% confidence interval (CI) 1.2-1.7, P 0.0001], intra- or postoperative RBC transfusion (OR: 1.6, 95% CI 1.4-1.9, P .0001), urinary tract infection (OR: 2.0, 95% CI 1.2-3.3, P = 0.0046), and length of stay5 days (OR: 1.3, 95% CI 1.1-1.5, P = 0.0015). Male sex was associated with higher rate of pulmonary (2.9% vs. 2.0%, P = 0.0344) and cardiac complications (0.9% vs. 0.5%, P = 0.0497). However, male sex as an independent risk factor for pulmonary (OR: 1.4, 95% CI 1.0-2.1, P = 0.0715) and cardiac complications (OR: 1.9, 95% CI 0.9-4.0, P = 0.1076) did not reach significance.Female sex was found to increase overall morbidity, particularly for urinary tract infection, transfusion, and length of stay5 days. Male sex was associated with greater incidence of pulmonary and cardiac complications. Thus, sex and other patient characteristics highlighted must be considered as part of surgical risk planning and patient counseling.3.

Retrospective study of prospectively collected data OBJECTIVE.: The aim of this study was to assess the impact of resident surgeon involvement on patient outcomes following posterior cervical fusion (PCF) surgery.Recently, there has been a significant uptrend in the number of PCF performed in the United States. Prior studies have investigated patient outcomes after cervical arthrodesis. Despite the heightened concern for patient safety and quality improvement, the data on the safety of resident participation in PCF is sparse.The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was examined from 2005 to 2012. Current Procedural Terminology codes were used to query the database for adults (≥18 years) who underwent PCF. Multivariate logistic regression models were employed on data adjusted by propensity scores to determine whether resident involvement was an independent predictor for the outcomes of interest.A total of 448 cases were assessed in NSQIP. Less than half of these cases involved residents (224, 43.1%). Resident involvement was found to be a significant predictor for blood transfusions [odds ratio (OR) = 1.7, confidence interval (CI) = 1.1-2.6, P = 0.010], length of stay of more than 5 days (OR = 1.6, CI = 1.0-2.6, P = 0.040), and operative time more than 4 hours (OR = 3.6, CI = 1.7-7.4, P = 0.0007). Other independent risk factors for prolonged length of stay included age 81 years or older versus 50 years or younger (OR = 4.7, CI = 1.7-12.6, P = 0.016) and diabetes (OR = 2.3, CI = 1.3-4.1, P = 0.006). In addition, multifusion was identified as a significant risk factor for extended operative time (OR = 1.8, CI = 1.1-2.9, P = 0.023).The present study used a large, nationwide sample to assess the impact of resident involvement in PCF. Resident participation was not associated with mortality, but had a minimal association with morbidity.3.