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Study Design: Retrospective cohort study., Objective: The purpose of this study is to determine which demographic, surgical, and radiographic preoperative characteristics are most associated with the need for subsequent fusion after decompression lumbar spinal surgery., Summary of Background Data: There is a relatively high rate of the need for repeat decompression or fusion after an index decompression procedure for degenerative spine disease. Nevertheless, there is a dearth of literature identifying risk factors for lumbar fusion following decompression surgery., Methods: Patients 18 years or older receiving a primary lumbar decompression surgery within the levels of L3-S1 between 2011 and 2020 were identified. All patients had preoperative radiographs and 2 years of follow-up data. Chart review was performed for surgical characteristics and demographics. The sagittal parameters included lumbar lordosis (LL), segmental lordosis (SL), anterior disk height (aDH), posterior disk height (pDH), sacral slope (SS), and pelvic tilt (PT). Pelvic incidence (PI=PT+SS) and pelvic incidence minus lumbar lordosis (PI-LL) were calculated. In addition, the Roussouly classification was determined for each patient. Bivariant and multivariant analyses were performed., Results: Of the 363 patients identified in this study, 96 patients had a fusion after their index decompression surgery. Multivariable analysis identified involvement of L4-L5 level in the decompression [odds ratio (OR)=1.83 (1.09-3.14), P =0.026], increased L5-S1 segmental lordosis [OR=1.08 (1.03-1.13), P =0.001], decreased SS [OR=0.96 (0.93-0.99), P =0.023], and decreased endplate obliquity [OR=0.88 (0.77-0.99), P =0.040] as significant independent predictors of fusion after decompression surgery., Conclusions: This is one of the first studies to assess preoperative sagittal parameters in conjunction with demographic variables to determine predictors of the need for fusion after index decompression. We demonstrated that decompression at L4-L5, greater L5-S1 segmental lordosis, decreased sacral slope, and decreased endplate obliquity were associated with higher rates of fusion after decompression surgery., Competing Interests: M.J.L. serves as on the editorial or governing board of BMC Musculoskeletal Disorders and Wolters Kluwer Health—Lippincott Williams & Wilkins. J.A.C. serves as a board/committee member for the Clinical Spine Research Society and has stock/stock options in PathKeeper Surgical. He receives research support from Accelus. M.F.K. is a paid consultatnt for Camber Spine and Spinal Elements. He has received royalty payments from Spinal Elements and Stryker and maintains stock or stock options with DuraStat LLC. I.D.K. is a paid consultant for Johnson & Johnson and Nuvasive. He receives research support from Camber Spine, as well as other financial support from Thieme. He serves on the board of the North American Spine Society and Spinal Cord and Case Series. A.S.H. receives royalties from Biomet and CTL Amedica and has stock or stock options with Paradigm Spine. A.R.V. serves as a board/committee member of the National Spine Health Foundation. He has received royalty payments from Medtronic, Stryker Spine, Globus, Aesculap, Thieme, Jaypee, Elsevier, and Taylor Francis/Hodder and Stoughton. He has stock/stock option ownership interests in Replication Medica, Globus, Paradigm Spine, Stout Medical, Progressive Spinal Technologies, Advanced Spinal Intellectual Properties, Spine Medica, Computational Biodynamics, Spinology, In Vivo, Flagship Surgical, Cytonics, Bonovo Orthopaedics, Electrocore, Gamma Spine, Location Based Intelligence, FlowPharma, R.S.I., Rothman Institute and Related Properties, Innovative Surgical Design, and Avaz Surgical. He has also served as deputy editor/editor of Spine. In addition, A.R.V. has also provided expert testimony. He has also served as deputy editor/editor of Clinical Spine Surgery. G.D.S. is a paid consultant for Advance Medical, Bioventus, and Surgalign. He serves on the board of Clinical Spine Surgery, AO Spine, Cervical Spine Research Society, and Wolters Kluwer Health—Lippincott Williams & Wilkins. He receives research support from Cerapedics, DePuy, A Johnson and Johnson Company, and Medtronic Sofamor Danek. C.K.K. serves on the editorial board of Clinical Spine Surgery and receives royalties from Curetiva and Regeneration Technologies Inc. The remaining authors report no conflicts of interest, (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Basic Science., Objective: The objective of this study was to identify a unique serum profile of circulating miRNAs and inflammatory markers in patients with degenerative cervical myelopathy (DCM) compared with healthy controls (HC)., Summary of Background Data: Currently, DCM is diagnosed with a combination of history, physical examination, and close correlation to advanced imaging. To date, no serum marker has been identified to be diagnostic of this condition., Methods: Whole venous blood was collected from patients with DCM as well as healthy age-matched and gender-matched controls. miRNA was extracted from venous blood, and a screening analysis was initially conducted to identify miRNA dysregulation in DCM patients. RT-qPCR was used to analyze the expression of 2 specific miRNAs based on screening analysis and literature review. Bioinformatics analysis was used to identify gene networks and potential targets of the miRNA. In addition, the serum inflammatory profile of DCM and HC groups was differentiated using a pro-inflammatory panel., Results: Thirty-six patients were enrolled in the DCM group (36.1% male, 61.5±9.5 y), while 35 patients were enrolled in the HC group (31.4% male, 57.5±8.9 y). Of the 15 total miRNAs differentially expressed between DCM and HC groups, two were selected for further analysis: miR-223-3p (upregulated) and miR-451a (downregulated). Functional gene network analysis revealed the highest-ranking gene network was involved in neurological disease, while the most overexpressed miRNA in this network (miR-233-3p) was noted to have over 100 targets, including CDKN1B and the insulin receptor. Serum cytokine analysis showed significant upregulation of several pro-inflammatory cytokines in the DCM cohort compared with the HC group., Conclusion: DCM patients demonstrated a set of unique circulating miRNAs in addition to a different serum inflammatory profile compared with HC. These miRNAs may potentially serve as targets for future therapeutic intervention or diagnostic/prognostic testing., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective cohort study., Objective: To compare outcomes in anteriorly placed transforaminal lumbar interbody fusions (TLIFs) and anterior lumbar interbody fusions (ALIFs)., Summary of Background Data: TLIF and ALIF are surgical techniques that have become more prevalent in recent years. Although studies have compared the two, none have considered TLIFs with anteriorly placed cages, which may serve as a better comparison to ALIFs., Patients and Methods: Patients undergoing TLIF or ALIF with posterior instrumentation from 2010 to 2020 at a tertiary care institution were retrospectively identified. TLIF cage position was assessed and those with anterior placement were included. Electronic medical records were reviewed to identify patient characteristics and patient-reported outcomes. Radiographic outcomes included posterior disc height (DH), lumbar lordosis (LL), sacral slope, pelvic incidence, and pelvic tilt. Statistical analysis was performed to compare the two groups., Results: Of the 351 patients, 108 had ALIF with posterior instrumentation and 207 had a TLIF. Preoperatively, patients undergoing TLIF had less LL (53.7° vs . 60.6°, P < 0.001), sacral slope (38.3° vs . 43.7°, P < 0.001), and pelvic incidence (60.1° vs . 66.1°, P < 0.001), all of which remained significant at 1-year and long-term follow-up ( P < 0.001). The TLIF group had less ∆DH (1.51° vs . 5.43°, P < 0.001), ∆LL (1.8° vs . 2.97°, P = 0.038), and ∆segmental lordosis (0.18° vs . 4.40°, P < 0.001) at 1 year postoperatively. At 2 to 3 years, ∆DH ( P < 0.001) and ∆segmental lordosis ( P = 0.001) remained significant, but ∆LL ( P = 0.695) did not. Patients in the TLIF group had higher Visual Analog Scale-Back scores 1 year postoperatively (3.68 vs . 2.16, P = 0.008) and experienced less improvement in Oswestry Disability Index (-17.1 vs . -28.6, P = 0.012) and Visual Analog Scale-Back (-2.67 vs . -4.50, P = 0.008) compared with patients undergoing ALIF., Conclusions: Our findings suggest that ALIF with posterior instrumentation performed superiorly in radiographic outcomes and patient-reported outcomes compared with anteriorly placed TLIFs. Anteriorly placed TLIF cages may not achieve the same results as those of ALIF cages., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Translational research., Objective: To evaluate the relative effects of NSAIDs, opioids, and a combination of the two on spinal fusion inhibition in a rodent model., Summary of Background Data: Nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids are common postoperative analgesic agents. Since NSAIDs inhibit the cyclooxygenase (COX) pathway, they are seldom prescribed following spinal fusion. Opioids may be given instead, but recent evidence suggests opioids also adversely affect spinal fusion quality and success., Methods: Eighty male Sprague-Dawley rats underwent L4-5 posterior lumbar fusion and were given one of the following analgesia regimens: saline, morphine (6 mg/kg), ketorolac (4 mg/kg), or morphine (3 mg/kg) and ketorolac (2 mg/kg). Serum samples were drawn to evaluate systemic pro-osteoblastic cytokines and vascular endothelial growth factor-A (VEGF-A) levels, which were measured through enzyme-linked immunosorbent assays (ELISA). After six weeks, the rats were sacrificed, and the operated spinal segments underwent manual palpation, microCT, and histologic analysis., Results: Manual palpation scores were significantly diminished in the opioid, NSAID, and multimodal groups when compared with control ( P <0.001). MicroCT fusion scores ( P <0.001) and fusion rates (control: 75% vs . NSAID: 35% vs . opioid: 0% vs . combination: 15%, P <0.001) were significantly diminished in the treatment groups. The bone volume (BV) to tissue volume (TV) ratio (BV/TV) ( P <0.001) and bone mineral density (BMD) ( P <0.001) were all lower in the treatment groups, with the opioid and combined groups having the lowest BMD. Although statistically insignificant ( P <0.09), the concentration of VEGF-A was greater in the control group compared with opioids, NSAIDs, and the combined group., Conclusion: Opioids and NSAIDs, both independently and combined, inhibited spinal fusion and caused inferior bony callus. Administration of opioids resulted in the lowest rate of spinal fusion. We propose this may be due to the inhibition of VEGF-A, which limits angiogenesis to the burgeoning fusion mass., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: The purpose of this study is to identify if construct length affects the rate of surgical complications and instrumentation revision following surgical fixation of subaxial and thoracolumbar Type B and C fractures. This study evaluates the effect of ankylosing spondylitis/diffuse idiopathic skeletal hyperostosis (AS/DISH) within this population on outcomes., Methods: Retrospective review of 91 cervical and 89 thoracolumbar Type B and C fractures. Groups were divided by construct length for analysis: short-segment (constructs spanning two or less segments adjacent to the fracture) and long-segment (constructs spanning more than two segments adjacent to the vertebral fracture)., Results: For cervical fractures, construct length did not impact surgical complications ( P = 0.641), surgical hardware revision ( P = 0.167), or kyphotic change ( P = 0.994). For thoracolumbar fractures, construct length did not impact surgical complications ( P = 0.508), surgical hardware revision ( P = 0.224), and kyphotic change ( P = 0.278). Cervical Type B fractures were nonsignificantly more likely to have worsened kyphosis ( P = 0.058) than Type C fractures. Assessing all regions of the spine, a diagnosis of AS/DISH was associated with an increase in kyphosis ( P = 0.030) and a diagnosis of osteoporosis was associated with surgical hardware failure ( P = 0.006)., Conclusion: Patients with short-segment instrumentation have similar surgical outcomes and changes in kyphosis compared to those with long-segment instrumentation. A diagnosis of AS/DISH or osteoporosis was associated with worse surgical outcomes., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Journal of Craniovertebral Junction and Spine.)

Objective: To quantify the burnout rate among physician associates/assistants (PAs) and NPs in a large orthopedic surgery practice affiliated with an academic institution., Methods: The Maslach Burnout Inventory (MBI) and original research questions were given to all PAs and NPs in orthopedics at the facility. Burnout was defined as a high level of emotional exhaustion or depersonalization on the MBI subscale., Results: Of the 129 PAs and NPs in orthopedics at our institution, 91 (70.5%) completed all survey items. Nearly 42% of respondents were burned out, as defined by high depersonalization or emotional exhaustion. PAs and NPs who met the burnout criteria were significantly older than those who did not (41.8 ± 10 versus 36.5 ± 7.71 years, P = .007) and spent longer in practice (12.4 ± 6.66 versus 9.35 ± 6.41 years, P = .01)., Conclusions: The prevalence of burnout is high among PAs and NPs in orthopedics who practice in an academic setting., (Copyright © 2024 American Academy of Physician Associates.)

Study Design: Systematic Review., Objective: To review the literature for complications and outcomes after the implantation of cellular bone matrix (CBM) during spine fusion., Methods: The PubMed database was queried from inception to January 31, 2023 for any articles that discussed the role of and identified a specific CBM in spinal fusion procedures. Adverse events, reoperations, methods, and fusion rates were collected from all studies and reported., Results: Six hundred articles were identified, of which 19 were included that reported outcomes of 7 different CBM products. Seven studies evaluated lumbar fusion, 11 evaluated cervical fusion, and 1 study reported adverse events of a single CBM product. Only 4 studies were comparative studies while others were limited to case series. Fusion rates ranged from 68% to 98.7% in the lumbar spine and 87% to 100% in the cervical spine, although criteria for radiographic fusion was variable. While 7 studies reported no adverse events, there was no strict consensus on what constituted a complication. One study reported catastrophic disseminated tuberculosis from donor contaminated CBM. The authors of 14 studies had conflicts of interest with either the manufacturer or distributor for their analyzed CBM., Conclusions: Current evidence regarding the use of cellular bone matrix as an osteobiologic during spine surgery is weak and limited to low-grade non-comparative studies subject to industry funding. While reported fusion rates are high, the risk of severe complications should not be overlooked. Further large clinical trials are required to elucidate whether the CBMs offer any benefits that outweigh the risks., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Study Design: Retrospective Cohort Study., Objectives: To (1) investigate the effect of marijuana use on surgical outcomes following lumbar fusion, (2) determine how marijuana use affects patient-reported outcomes measures (PROMs), and (3) determine if marijuana use impacts the quantity of opioids prescribed., Methods: Patients > 18 years of age who underwent primary one- or two-level lumbar fusion with preoperative marijuana use at our institution were identified. A 3:1 propensity match incorporating patient demographics and procedure type was conducted to compare preoperative marijuana users to non-marijuana users. Patient demographics, surgical characteristics, surgical outcomes (90-day all-cause and 90-day surgical readmissions, reoperations, and revision surgeries), pre- and postoperative narcotic usage, and PROMs were compared between groups. Multivariate regression models were created to determine the effect of marijuana on surgical reoperations patient-reported outcomes (PROMs) 1-year postoperatively., Results: Of the 259 included patients, 65 used marijuana preoperatively. Multivariate logistic regression analysis demonstrated that marijuana use (OR = 2.28, P = .041) significantly increased the likelihood of having a spine reoperation. No other surgical outcome was found to be significantly different between groups. Multivariate linear regression analysis showed that marijuana use was not significantly associated with changes in 1-year postoperative PROMs (all, P > .05). The quantity of pre- and postoperative opioids prescriptions was not significantly different between groups (all, P > .05)., Conclusions: Preoperative marijuana use increased the likelihood of a spine reoperation for any indication following lumbar fusion, but it was not associated with 90-day all cause readmission, surgical readmission, the magnitude of improvement in PROMs, or differences in opioid consumption., Level of Evidence: III., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Study Design: Retrospective Cohort., Objectives: To (1) quantify the risk opioids impart on pseudarthrosis development, (2) analyze the effect of pseudarthrosis on clinical outcomes, and (3) identify if the amount of opioids prescribed are predictive of pseudarthrosis revision., Methods: Patients who underwent ACDF at a single institution between 2017-2019 were retrospectively identified. Postoperative dynamic cervical spine radiographs were reviewed to assess fusion status. Logistic regression models measured the effect of morphine milligram equivalents (MME) prescribed on the likelihood of pseudarthrosis development. Receiver operating characteristic (ROC) curves were generated to predict the probability of surgical revision based on MME prescribed., Results: Of 298 included patients, an average of 2.01 ± 0.82 levels were included in the construct and 121 (40.9%) patients were diagnosed with a pseudarthrosis. However, only 14 (4.7%) required a pseudarthrosis revision. Patients requiring pseudarthrosis revision had worse one-year postoperative Δ PCS-12 (-1.70 vs. 7.58, P = 0.004), Δ NDI (3.33 vs. -15.26, P = 0.002), and Δ VAS Arm (2.33 vs. -2.48, P = .047). Multivariate logistic regression analyses found the three-month postoperative (OR=1.00, P = .010), one-year postoperative (OR=1.001, P = 0.025), and combined pre- and postoperative MME (OR=1.000, P = .035) increased the risk of pseudarthrosis. ROC analysis identified cutoff values to predict pseudarthrosis revision at 90.00 (area under the curve (AUC): 0.693, confidence interval (CI): 0.554-0.832), 132.86 (0.710, CI: 0.589-0.840), 224.76 (0.687, CI: 0.558-0.817) and 285.00 (0.711, CI: 0.585-0.837) MME in the preoperative, three-month postoperative, one-year postoperative, and combined pre-and postoperative period., Conclusion: Increased prescription of opioid medications following ACDF procedures may increase the risk of pseudarthrosis development and revision surgery., Level of Evidence: Therapeutic Level III., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Study Design: Retrospective single-institution cohort., Objective: To evaluate the implementation of a commercial bundled payment model in patients undergoing lumbar spinal fusion., Summary of Background Data: BPCI-A caused significant losses for many physician practices, prompting private payers to establish their own bundled payment models. The feasibility of these private bundles has yet to be evaluated in spine fusion., Methods: Patients undergoing lumbar fusion from October to December 2018 in BPCI-A before our institution's departure were included for BPCI-A analysis. Private bundle data was collected from 2018 to 2020. Analysis of the transition was conducted among Medicare-aged beneficiaries. Private bundles were grouped by calendar year (Y1, Y2, Y3). Stepwise multivariate linear regression was performed to measure independent predictors of net deficit., Results: The net surplus was the lowest in Y1 ($2,395, P =0.03) but did not differ between our final year in BPCI-A and subsequent years in private bundles (all, P >0.05). AIR and SNF patient discharges decreased significantly in all private bundle years compared with BPCI. Readmissions fell from 10.7% (N=37) in BPCI-A to 4.4% (N=6) in Y2 and 4.5% (N=3) Y3 of private bundles ( P <0.001). Being in Y2 or Y3 was independently associated with a net surplus in comparison to the Y1 (β: $11,728, P =0.001; β: $11,643, P =0.002). Postoperatively, length of stay in days (β: $-2,982, P <0.001), any readmission (β: -$18,825, P =0.001), and discharge to AIR (β: $-61,256, P <0.001) or SNF (β: $-10,497, P =0.058) were all associated with a net deficit., Conclusions: Nongovernmental bundled payment models can be successfully implemented in lumbar spinal fusion patients. Constant price adjustment is necessary so bundled payments remain financially beneficial to both parties and systems overcome early losses. Private insurers who have more competition than the government may be more willing to provide mutually beneficial situations where cost is reduced for payers and health systems., Level of Evidence: 3., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To evaluate the (1) 90-day surgical outcomes and (2) 1-year revision rate of robotic versus nonrobotic lumbar fusion surgery., Methods: Patients >18 years of age who underwent primary lumbar fusion surgery at our institution were identified and propensity-matched in a 1:1 fashion based on robotic assistance during surgery. Patient demographics, surgical characteristics, and surgical outcomes, including 90-day surgical complications and 1-year revisions, were collected. Multivariable regression analysis was performed. Significance was set to P < 0.05., Results: Four hundred and fifteen patients were identified as having robotic lumbar fusion and were matched to a control group. Bivariant analysis revealed no significant difference in total 90-day surgical complications ( P = 0.193) or 1-year revisions ( P = 0.178). The operative duration was longer in robotic surgery (287 + 123 vs. 205 + 88.3, P ≤ 0.001). Multivariable analysis revealed that robotic fusion was not a significant predictor of 90-day surgical complications (odds ratio [OR] = 0.76 [0.32-1.67], P = 0.499) or 1-year revisions (OR = 0.58 [0.28-1.18], P = 0.142). Other variables identified as the positive predictors of 1-year revisions included levels fused (OR = 1.26 [1.08-1.48], P = 0.004) and current smokers (OR = 3.51 [1.46-8.15], P = 0.004)., Conclusion: Our study suggests that robotic-assisted and nonrobotic-assisted lumbar fusions are associated with a similar risk of 90-day surgical complications and 1-year revision rates; however, robotic surgery does increase time under anesthesia., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Journal of Craniovertebral Junction and Spine.)

Study Design: Retrospective Cohort., Objective: To determine if outcomes varied between patients based on physical therapy (PT) attendance after lumbar fusion surgery., Summary of Background Data: The literature has been mixed regarding the efficacy of postoperative PT to improve disability and back pain, as measured by patient-reported outcome measures. Given the prevalence of PT referrals and lack of high-quality evidence, there is a need for additional studies investigating the efficacy of PT after lumbar fusion surgery to aid in developing robust clinical guidelines., Methods: We retrospectively identified patients receiving lumbar fusion surgery by current procedural terminology codes and separated them into 2 groups based on whether PT was prescribed. Electronic medical records were reviewed for patient and surgical characteristics, PT utilization, and surgical outcomes. Patient-reported outcome measures (PROMs) were identified and compared preoperatively, at 90 days postoperatively and one year postoperatively., Results: The two groups had similar patient characteristics and comorbidities and demonstrated no significant differences between readmission, complication, and revision rates after surgery. Patients that attended PT had significantly more fused levels (1.41 ± 0.64 vs. 1.32 ± 0.54, P =0.027), longer operative durations (234 ± 96.4 vs. 215 ± 86.1 min, P =0.012), and longer postoperative hospital stays (3.35 ± 1.68 vs. 3.00 ± 1.49 days, P =0.004). All groups improved similarly by Oswestry Disability Index, short form-12 physical and mental health subsets, and back and leg pain by Visual Analog Scale at 90-day and 1-year follow-up., Conclusion: Our data suggest that physical therapy does not significantly impact PROMs after lumbar fusion surgery. Given the lack of data suggesting clear benefit of PT after lumbar fusion, surgeons should consider more strict criteria when recommending physical therapy to their patients after lumbar fusion surgery., Level of Evidence: Level-Ⅲ., Competing Interests: Dr. Schroeder has received funds to travel from AO Spine and Medtronic. Dr. Vaccaro has consulted or has done independent contracting for DePuy, Medtronic, Stryker Spine, Globus, Stout Medical, Gerson Lehrman Group, Guidepoint Global, Medacorp, Innovative Surgical Design, Orthobullets, Ellipse, and Vertex. He has also served on the scientific advisory board/board of directors/committees for Flagship Surgical, AO Spine, Innovative Surgical Design, and Association of Collaborative Spine Research. Dr. Vaccaro has received royalty payments from Medtronic, Stryker Spine, Globus, Aesculap, Thieme, Jaypee, Elsevier, and Taylor Francis/Hodder and Stoughton. He has stock/stock option ownership interests in Replication Medica, Globus, Paradigm Spine, Stout Medical, Progressive Spinal Technologies, Advanced Spinal Intellectual Properties, Spine Medica, Computational Biodynamics, Spinology, In Vivo, Flagship Surgical, Cytonics, Bonovo Orthopaedics, Electrocore, Gamma Spine, Location Based Intelligence, FlowPharma, R.S.I., Rothman Institute and Related Properties, Innovative Surgical Design, and Avaz Surgical. He has also served as deputy editor/editor of Spine. In addition, Dr Vaccaro has also provided expert testimony. He has also served as deputy editor/editor of Clinical Spine Surgery. The remaining authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Although bundled payment models are well-established in Medicare-aged individuals, private insurers are now developing bundled payment plans. The role of these plans in spine surgery has not been evaluated. Our objective was to analyze the performance of a private insurance bundled payment program for lumbar decompression and microdiskectomy., Methods: A retrospective review was conducted of all lumbar decompressions in a private payer bundled payment model at a single institution from October 2018 to December 2020. 120-day episode of care cost data were collected and reported as net profit or loss regarding set target prices. A stepwise multivariable linear regression model was developed to measure the effect of patient and surgical factors on net surplus or deficit., Results: Overall, 151 of 468 (32.2%) resulted in a deficit. Older patients (58.6 vs. 50.9 years, P < 0.001) with diabetes (25.2% vs. 13.9%, P = 0.004), hypertension (38.4% vs. 28.4%, P = 0.038), heart disease (13.9% vs. 7.57%, P = 0.030), and hyperlipidemia (51.7% vs. 35.6%, P = 0.001) were more likely to experience a loss. Surgically, decompression of more levels (1.91 vs. 1.19, P < 0.001), posterior lumbar decompression (86.8% vs. 56.5%, P < 0.001), and performing surgery at a tertiary hospital (84.8% vs. 70.3%, P < 0.001) were more likely to result in loss. All readmissions resulted in a loss (4.64% vs. 0.0%, P < 0.001). On multivariable regression, microdiskectomy (β: $2,398, P = 0.012) and surgery in a specialty hospital (β: $1,729, P = 0.096) or ambulatory surgery center (β: $3,534, P = 0.055) were associated with cost savings. Increasing number of levels, longer length of stay, active smoking, and history of cancer, dementia, or congestive heart failure were all associated with degree of deficit., Conclusions: Preoperatively optimizing comorbidities and using risk stratification to identify those patients who may safely undergo surgery at a facility other than an inpatient hospital may help increase cost savings in a bundled payment model of working-age and Medicare-age individuals., Competing Interests: Conflicts of Interest and Source of Funding : The authors, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article. There are no relevant disclosures., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Study Design: Retrospective cohort analysis., Objective: To determine, which patient-specific risk factors increase total episode of care (EOC) costs in a population of Centers for Medicare and Medicaid Services beneficiaries undergoing lumbar decompression., Summary of Background Data: Lumbar decompression is an effective option for the treatment of central canal stenosis or radiculopathy in patients unresponsive to nonoperative management. Given that elderly Americans are more likely to have one or more chronic medical conditions, there is a need to determine, which, if any, patient-specific risk factors increase health care costs after lumbar decompression., Methods: Care episodes limited to lumbar decompression surgeries were retrospectively reviewed on a Centers for Medicare and Medicaid Service reimbursement database at our academic institution between 2014 and 2019. The 90-day total EOC reimbursement payments were collected. Patient electronic medical records were then matched to the selected care episodes for the collection of patient demographics, medical comorbidities, surgical characteristics, and clinical outcomes. A stepwise multivariate linear regression model was developed to predict patient-specific risk factors that increased total EOC costs after lumbar decompression. Significance was set at P <0.05., Results: A total of 226 patients were included for analysis. Risk factors associated with increased total EOC cost included increased age (per year) (β = $324.70, P < 0.001), comorbid depression (β = $4368.30, P = 0.037), revision procedures (β = $6538.43, P =0.012), increased hospital length of stay (per day) (β = $2995.43, P < 0.001), discharge to an inpatient rehabilitation facility (β = $14,417.42, P = 0.001), incidence of a complication (β = $8178.07, P < 0.001), and readmission (β = $18,734.24, P < 0.001) within 90 days., Conclusions: Increased age, comorbid depression, revision decompression procedures, increased hospital length of stay, discharge to an inpatient rehabilitation facility, and incidence of a complication and readmission within 90 days were all associated with increased total episodes of care costs., Competing Interests: Dr Schroeder has received funds to travel from AOSpine and Medtronic. Dr Vaccaro has consulted or has done independent contracting for DePuy, Medtronic, Stryker Spine, Globus, Stout Medical, Gerson Lehrman Group, Guidepoint Global, Medacorp, Innovative Surgical Design, Orthobullets, Ellipse, and Vertex. He has also served on the scientific advisory board/board of directors/committees for Flagship Surgical, AOSpine, Innovative Surgical Design, and Association of Collaborative Spine Research. Dr Vaccaro has received royalty payments from Medtronic, Stryker Spine, Globus, Aesculap, Thieme, Jaypee, Elsevier, and Taylor Francis/Hodder and Stoughton. He has stock/stock option ownership interests in Replication Medica, Globus, Paradigm Spine, Stout Medical, Progressive Spinal Technologies, Advanced Spinal Intellectual Properties, Spine Medica, Computational Biodynamics, Spinology, In Vivo, Flagship Surgical, Cytonics, Bonovo Orthopedics, Electrocore, Gamma Spine, Location Based Intelligence, FlowPharma, R.S.I., Rothman Institute and Related Properties, Innovative Surgical Design, and Avaz Surgical. He has also served as deputy editor/editor of Spine. In addition, Dr Vaccaro has also provided expert testimony. He has also served as deputy editor/editor of Clinical Spine Surgery. The remaining authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background Context: Bundled payment models require risk adjustment to ensure appropriate targets are set. While this may be standardized for many services, spine fusions demonstrate significant variability in approach, invasiveness, and use of implants, that may require further risk adjustment., Purpose: To evaluate variability in costs of spinal fusion episodes in a private insurer bundle payment program and identify whether current procedural terminology (CPT) code modifications are necessary for sustainable implementation., Study Design/setting: Retrospective single-institution cohort study., Patient Sample: A total of 542 lumbar fusion episodes in a private insurer bundled payment program from October 2018 to December 2020., Outcome Measures: A total of 120-day episode of care net surplus/deficit, 90-day readmissions, discharge disposition, and length of hospital stay., Methods: A review was conducted of all lumbar fusions in a single institution's payer database. Surgical characteristics (approach [posterior lumbar decompression and fusion (PLDF), transforaminal lumbar interbody fusion (TLIF), and circumferential fusion], levels fused, and primary vs revision) were collected from manual chart review. Episode of care cost data were collected as net surplus or deficit with respect to target prices. A multivariate linear regression model was constructed to measure the independent effects of primary versus revision, levels fused, and approach on the net cost savings., Results: Most procedures were PLDFs (N=312, 57.6%), single-level (N=416, 76.8%) and primary fusions (N=477, 88.0%). Overall, 197 (36.3%) resulted in a deficit, and were more likely to be three levels (7.11% vs 2.03%, p=.005), revisions (18.8% vs 8.12%, p<.001), and TLIF (47.7% vs 35.1%, p<.001) or circumferential fusions (p<.001). One-level PLDFs resulted in the greatest cost savings per episode ($6,883). Across both PLDFs and TLIFs, 3-level procedures resulted in significant deficit of -$23,040 and -$18,887, respectively. For circumferential fusions, 1-level fusions resulted in deficit of -$17,169 per case which rose to -$64,485 and -$49,222 for 2- and 3-level fusions. All 2- and 3-level circumferential spinal fusions resulted in a deficit. On multivariable regression, TLIF and circumferential fusions were independently associated with a deficit of -$7,378 (p=.004) and -$42,185 (p<.001), respectively. Three-level fusions were independently associated with an additional -$26,003 deficit compared to single-level fusions (p<.001)., Conclusions: Interbody fusions, especially circumferential fusions, and multi-level procedures are not adequately risk adjusted by current bundled payment models. Health systems may not be able to financially support these alternative payment models with improved procedure-specific risk adjustment., Competing Interests: Declaration of competing interest Dr. Vaccaro reports other from Advanced Spinal Intellectual Properties, personal fees from Aesculap, other from AO Spine, personal fees and other from Atlas Spine, other from Avaz Surgical, other from Bonovo Orthopaedics, other from Computational Biodynamics, other from Cytonics, other from Deep Health, other from Dimension Orthotics LLC, other from Electrocore, personal fees from Elsevier, other from Flagship Surgical, other from FlowPharma, personal fees and other from Globus, other from Innovative Surgical Design, personal fees and other from Jaypee, other from Jushi (Haywood) , personal fees from Medtronics, other from National Spine Health Foundation, other from Nuvasive, other from Orthobullets, other from Parvizi Surgical Innovation, other from Progressive Spinal Technologies, other from Replication Medica, other from Sentryx, other from Spine Medica, other from Spineology, other from Spine Wave, other from Stout Medical, personal fees from Stryker Spine, personal fees from Taylor Francis/Hodder and Stoughton, personal fees from Thieme, other from ViewFi Health, other from Accellus, other from AVKN Patient Driven Care, other from Harvard Medtech, outside the submitted work. And the other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background Context: High serum nicotine levels increase the risk of nonunion after spinal fusion. Varenicline, a pharmaceutical adjunct for smoking cessation, is a partial agonist designed to displace and outcompete nicotine at its receptor binding site, thereby limiting downstream activation. Given its mechanism, varenicline may have therapeutic benefits in mitigating nonunion for active smokers undergoing spinal fusion., Purpose: To compare fusion rate and fusion mass characteristics between cohorts receiving nicotine, varenicline, or concurrent nicotine and varenicline after lumbar fusion., Study Design: Rodent noninstrumented spinal fusion model., Methods: Sixty eight-week-old male Sprague-Dawley rats weighing approximately 300 grams underwent L4-5 posterolateral fusion (PLF) surgery. Four experimental groups (control: C, nicotine: N, varenicline: V, and combined: NV [nicotine and varenicline]) were included for analysis. Treatment groups received nicotine, varenicline, or a combination of nicotine and varenicline delivered through subcutaneous osmotic pumps beginning two weeks before surgery until the time of sacrifice at age 14 weeks. Manual palpation testing, microCT imaging, bone histomorphometry, and biomechanical testing were performed on harvested spinal fusion segments., Results: Control (p=0.016) and combined (p=0.032) groups, when compared directly to the nicotine group, demonstrated significantly greater manual palpation scores. The fusion rate in the control (93.3%) and combined (93.3%) groups were significantly greater than that of the nicotine group (33.3%) (p=0.007, both). Biomechanical testing demonstrated greater Young's modulus of the fusion segment in the control (17.1 MPa) and combined groups (34.5 MPa) compared to the nicotine group (8.07 MPa) (p<0.001, both). MicroCT analysis demonstrated greater bone volume fraction (C:0.35 vs N:0.26 vs NV:0.33) (p<0.001, all) and bone mineral density (C:335 vs N:262 vs NV:328 mg Ha/cm 3 ) (p<0.001, all) in the control and combined groups compared to the nicotine group. Histomorphometry demonstrated a greater mineral apposition rate in the combined group compared to the nicotine group (0.34 vs 0.24 μm/day, p=0.025)., Conclusion: In a rodent spinal fusion model, varenicline mitigates the adverse effects of high nicotine serum levels on the rate and quality of spinal fusion., Clinical Significance: These findings have the potential to significantly impact clinical practice guidelines and the use of pharmacotherapy for active nicotine users undergoing fusion surgery., Competing Interests: Declaration of Competing Interest One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: The objectives of our study were to (1) determine if physical therapy (PT) impacts patient-reported outcomes (PROMs) after lumbar decompression surgery and (2) determine if PT impacts postsurgical readmissions or reoperations after lumbar decompression surgery., Methods: Patients > 18 years of age who underwent primary one- or two-level lumbar decompression at our institution were identified. Patient demographics, surgical characteristics, surgical outcomes (all-cause 90 days readmissions and 90 days surgical readmissions), and patient-reported outcomes (PROMs) were compared between the groups. Multivariate linear regression was utilized to determine the individual predictors of 90 days readmissions and PROMs at the 1-year postoperative point. Alpha was set at P < 0.05., Results: Of the 1003 patients included, 421 attended PT postoperatively. On univariate analysis, PT attendance did not significantly impact 90-day surgical reoperations ( P = 0.225). Although bivariate analysis suggests that attendance of PT is associated with worse improvement in physical function ( P = 0.041), increased preoperative Visual Analogue Scale leg pain (0 = 0.004), and disability ( P = 0.006), as measured by the Oswestry Disability Index, our multivariate analysis, which accounts for confounding variables found there was no difference in PROM improvement and PT was not an independent predictor of 90-day all-cause readmissions ( P = 0.06). Instead, Charlson Comorbidity Index ( P = 0.025) and discharge to a skilled nursing facility ( P = 0.013) independently predicted greater 90-day all-cause readmissions., Conclusions: Postoperative lumbar decompression PT attendance does not significantly affect clinical improvement, as measured by PROMs or surgical outcomes including all-cause 90 days readmissions and 90-day surgical readmissions., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Journal of Craniovertebral Junction and Spine.)

Objective: To assess the impact of central stenosis severity on patient-reported outcomes after lumbar decompression., Methods: Patient diagnosis, demographics, and surgical characteristics were collected via query search and manual chart review of electronic medical records. The inclusion criteria were posterior lumbar decompressions from 2014-2020, with accessible magnetic resonance imaging reports. As previously validated by Lee et al., central stenosis was determined on magnetic resonance imaging and graded as none, mild, moderate, or severe. Patients were dichotomized into 2 groups to improve statistical power for comparisons: none or mild central stenosis and moderate or severe central stenosis. Patient-reported outcome measures (PROMs) were compared between cohorts at 1 year postoperatively. Statistical significance was set at P < 0.05., Results: On bivariate analysis, no significant differences were noted between cohorts with regard to preoperative, 1-year postoperative, and delta PROMs. In addition, no significant difference in the number of patients attaining minimal clinically important difference (MCID) for each PROM was noted between cohorts. With the exception of mental score of the Short Form-12 survey, all intragroup preoperative to postoperative PROMs indicated significant improvement (all P < 0.05) after lumbar decompression surgery. Multivariate regression identified moderate or severe central canal stenosis as a significant independent predictor of improvement in visual analog scale back (estimate = -1.464, P = 0.045)., Conclusions: We demonstrate that patients with moderate or severe central spinal stenosis may have more improvement in back pain than those with mild or no central stenosis after lumbar spine decompression surgery., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: The relationship between research productivity in training and future productivity as an attending spine surgeon is not well-established in the literature nor has the effect of geographic location of training institutions on future academic success been investigated. The aim of our study was to (1) summarize characteristics of academically productive spine surgeons, (2) assess predictors of long-term academic productivity, and (3) establish the effect of geographic location on long-term academic productivity., Methods: A query was conducted of the 2021 to 2022 North American Spine Society Spine Fellowship Directory of all orthopaedic and neurosurgical spine fellowship selection committee members for each institution participating in the spine fellowship match. The attending publication rate and h- index were determined. A multivariate linear regression model was developed. P value was set to <0.05., Results: We identified 310 orthopaedic and neurosurgical spine surgeons, representing 76 fellowship programs. Multivariate linear regression analysis identified that the publications during residency ( P < 0.001) and during fellowship ( P < 0.001) were significant predictors of an increased publication rate as an attending surgeon. By contrast, the preresidency publication rate ( P = 0.729) was not significantly predictive of the attending publication rate. Multivariate analysis of h- index found that residency publication rate had a positive correlation ( P = 0.031) compared with preresidency ( P = 0.579) or fellowship ( P = 0.257) rates. Attendings who had attended residency in the Northeast and currently practicing in the Northeast had a higher publication rate ( P < 0.001 and P = 0.004, respectively)., Discussion: A higher number of publications in residency and fellowship were markedly predictive of an increased publication rate as an attending spine surgeon. By contrast, preresidency publications may not be indicative of future academic productivity as an attending. Location may also contribute to attending publication rate and favor those who undergo residency training and ultimately practice in the Northeast., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Study Design: Retrospective cohort study., Objective: To compare infection rates before and after the implementation of a quality improvement protocol focused on methicillin-resistant Staphylococcus aureus (MRSA) screening and decolonization in patients undergoing lumbar fusion and/or decompression., Summary of Background Data: Prior studies have demonstrated MRSA infections comprise a sizable portion of SSIs. Additional studies are required to improve our understanding of the risks and benefits of MRSA decolonization with vancomycin prophylaxis., Methods: A retrospective cohort analysis was conducted on patients who underwent spinal fusion or laminectomy before (2008-2011) and after (2013-2016) the implementation of an MRSA screening and treatment protocol. Odds ratios for MRSA, methicillin-sensitive Staphylococcus aureus (MSSA), and Vancomycin-resistant Enterococcus (VRE) infection before and after screening was calculated. Multivariate analysis assessed demographic characteristics as potential independent predictors of infection., Results: A total of 8425 lumbar fusion and 2558 lumbar decompression cases met inclusion criteria resulting in a total cohort of 10,983 patients. There was a significant decrease in the overall rate of infections ( P <0.001), MRSA infections ( P <0.001), and MSSA infections ( P <0.001) after protocol implementation. Although VRE infections after protocol implementation were not significantly different ( P =0.066), VRE rates as a percentage of all postoperative infections were substantially increased (0 vs. 3.36%, P =0.007). On multivariate analysis, significant predictors of the infection included younger age (OR=0.94[0.92-0.95]), shorter length of procedure (OR=1.00[0.99-1.00]), spinal fusion (OR=18.56[8.22-53.28]), higher ASA class (OR=5.49[4.08-7.44]), male sex (OR=1.61[1.18-2.20]), and history of diabetes (OR=1.58[1.08-2.29])., Conclusion: The implemented quality improvement protocol demonstrated that preoperative prophylactically treating MRSA colonized patients decreased the rate of overall infections, MSSA infections, and MRSA infections. In addition, younger age, male sex, diabetic status, greater ASA scores, and spinal fusions were risk factors for postoperative infection., Competing Interests: The authors, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article. There are no relevant disclosures. Dr Schroeder has received funds to travel from AOSpine and Medtronic. Dr Vaccaro has consulted or has done independent contracting for DePuy, Medtronic, Stryker Spine, Globus, Stout Medical, Gerson Lehrman Group, Guidepoint Global, Medacorp, Innovative Surgical Design, Orthobullets, Ellipse, and Vertex. He has also served on the scientific advisory board/board of directors/committees for Flagship Surgical, AO Spine, Innovative Surgical Design, and Association of Collaborative Spine Research. Dr. Vaccaro has received royalty payments from Medtronic, Stryker Spine, Globus, Aesculap, Thieme, Jaypee, Elsevier, and Taylor Francis/Hodder and Stoughton. He has stock/stock option ownership interests in Replication Medica, Globus, Paradigm Spine, Stout Medical, Progressive Spinal Technologies, Advanced Spinal Intellectual Properties, Spine Medica, Computational Biodynamics, Spinology, In Vivo, Flagship Surgical, Cytonics, Bonovo Orthopaedics, Electrocore, Gamma Spine, Location Based Intelligence, FlowPharma, R.S.I., Rothman Institute and Related Properties, Innovative Surgical Design, and Avaz Surgical. In addition, Dr Vaccaro has also provided expert testimony. He has also served as deputy editor/editor of Clinical Spine Surgery. The remaining authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Case: Although implanted tuberculosis (TB) is rare, a single lot of cellular bone matrix was found to be infected with TB, leading to devastating outcomes. We present 2 cases referred to our institution because of instrumentation failure caused by TB inoculation of cellular bone matrix., Conclusion: Irrespective of spinal region of implanted TB infection, excision of infected bone, extensive irrigation and debridement, and instrumented stabilization are of primary importance to ensure TB eradication and adequate stabilization., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C93)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Objectives: The objectives of our study were to compare the fusion rates and surgical outcomes of lumbar fusion surgery based on the (1) type of demineralized bone matrix (DBM) carrier allograft, (2) the presence/absence of a carrier, and (3) the presence of bone fibers in DBM., Methods: Patients >18 years of age who underwent single-level posterolateral decompression and fusion (PLDF) between L3 and L5 between 2014 and 2021 were retrospectively identified. We assessed bone grafts based on carrier type (no carrier, sodium hyaluronate carrier, and glycerol carrier) and the presence of bone fibers. Fusion status was determined based on a radiographic assessment of bony bridging, screw loosening, or change in segmental lordosis >5°. Analyses were performed to assess fusion rates and surgical outcomes., Results: Fifty-four patients were given DBM with a hyaluronate carrier, 75 had a glycerol carrier, and 94 patients were given DBM without a carrier. DBM carrier type, bone fibers, and carrier presence had no impact on 90-day readmission rates ( P = 0.195, P = 0.099, and P = 1.000, respectively) or surgical readmissions ( P = 0.562, P = 0.248, and P = 0.640, respectively). Multivariable logistic regression analysis found that type of carrier, presence of fibers (odds ratio [OR] = 1.106 [0.524-2.456], P = 0.797), and presence of a carrier (OR = 0.701 [0.370-1.327], P = 0.274) were also not significantly associated with successful fusion likelihood., Conclusion: Our study found no significant differences between DBM containing glycerol, sodium hyaluronate, or no carrier regarding fusion rates or surgical outcomes after single-level PLDF. Bone particulates versus bone fibers also had no significant differences regarding the likelihood of bony fusion., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Journal of Craniovertebral Junction and Spine.)

Objective: The authors sought to determine if postoperative disc height loss is associated with pseudarthrosis following anterior cervical discectomy and fusion (ACDF). They also sought to determine if the amount of postoperative disc height loss is predictive of need for revision for pseudarthrosis, as well as the impact of postoperative disc height loss on patient-reported outcome measures (PROMs) following surgery., Methods: The authors retrospectively identified patients aged > 18 years who underwent primary one- to three-level ACDF with allograft at a single institution with 1-year postoperative lateral and flexion-extension cervical spine radiographs. Logistic regression models and receiver operating characteristic curves were used for analysis. Alpha was set at p < 0.05., Results: Anterior or posterior disc height loss ≥ 2 mm was found in 52.5% of patients. Patients with a loss ≥ 2 mm were more likely to develop pseudarthrosis (p = 0.021) but not to undergo revision surgery due to pseudarthrosis (p = 0.459). Multivariable analysis identified male sex (OR 1.66, p = 0.013), the number of levels fused (OR 2.09, p < 0.001), and fusion at C6-7 (OR 1.52, p = 0.043) as predictors of disc height loss. The analysis also revealed that levels at the top (OR 0.383, 95% CI 0.170-0.854, p = 0.020) and middle (OR 0.174, 95% CI 0.053-0.548, p = 0.003) of fusion constructs were significant independent predictors of lower pseudarthrosis rates while disc height loss was not. Patients with disc height loss had significantly less improvement in scores for the Neck Disability Index (p = 0.002), visual analog scale (VAS) for arm pain (p = 0.018), and VAS for neck pain (p = 0.011) at 1 year following surgery., Conclusions: This study is, to the authors' knowledge, the largest study to date to assess the impact of postoperative disc height loss after ACDF. Disc height loss following ACDF was not predictive of revision surgery for pseudarthrosis or overall pseudarthrosis rates. However, pseudarthrosis was less likely to occur at the top and middle of fusion constructs. Loss in disc height postoperatively was significantly associated with less improvement in PROMs.

Introduction: Primary hip and knee arthroplasty represent two of the most successful orthopaedic surgical interventions in the past century. Similarly, lumbar fusion (LF) remains a valuable, evidence-based option to relieve pain and disability related to spinal degenerative conditions. This study evaluates the relative improvements in 1-year health-related quality of life (HRQOL) measures among patients undergoing primary single-level LF, primary total hip arthroplasty (THA), and primary total knee arthroplasty (TKA)., Methods: Patients older than 18 years who underwent primary single-level posterior LF (posterolateral decompression and fusion with or without transforaminal lumbar interbody fusion, involving any single lumbar level), TKA, and THA at a single academic institution were retrospectively identified. Patient demographics and surgical characteristics were collected. HRQOL measures were collected preoperatively and at 1-year postoperative time point including Short-Form 12 Physical Component Score (PCS) and Mental Component Score (MCS) along with subspecialty-specific outcomes., Results: A total of 2,563 patients were included (346 LF, 1,035 TKA, and 1,182 THA). Change in MCS-12 and PCS-12 after LF did not vary markedly by preoperative diagnosis. LF patients had a significantly lower preoperative MCS-12 (LF: 50.8, TKA: 53.9, THA: 52.9, P < 0.001), postoperative MCS-12 (LF: 52.5, TKA: 54.8, THA: 54.5, P < 0.001), postoperative PCS-12 (LF: 40.1, TKA: 44.0, THA: 43.9, P < 0.001), ΔPCS-12 (LF: 7.9, TKA: 10.8, THA: 11.9, P < 0.001), and PCS-12 recovery ratio (LF: 10.7%, TKA: 15.1%, THA 16.6%, P < 0.001) compared with TKA and THA patients. In regression analysis, both TKA and LF were found to be independently associated with a smaller ΔPCS-12 improvement (TKA: β = -1.36, P = 0.009; LF: β = -4.74, P < 0.001) compared with THA. TKA (β = -1.42, P = 0.003) was also independently associated with a smaller ΔMCS-12 improvement compared with THA., Conclusions: Patients undergoing single-level LF, TKA, and THA demonstrate notable improvements in HRQOL outcomes at 1 year postoperatively compared with preoperative baseline scores. The greatest improvements were found among THA patients, followed subsequently by TKA and LF patients. Both LF and TKA were independently associated with markedly less improvement in physical disability at 1 year postoperatively compared with THA., Study Design: Retrospective Cohort Study., (Copyright © 2022 by the American Academy of Orthopaedic Surgeons.)

Objective: To determine if closed incision negative pressure wound therapy (ciNPWT) decreases surgical site infection (SSI) or wound dehiscence after spinal fusion., Methods: Following PRISMA guidelines, a systematic review and meta-analysis were conducted to identify studies using ciNPWT after spinal fusion. Funnel plots and quality scores of the articles were performed to determine if the articles were at risk of bias. Forest plots were conducted to identify the treatment effect of ciNPWT after spinal fusion., Results: A total of 8 studies comprising 1061 patients who received ciNPWT or a standard postoperative dressing after spinal fusion were included. The rate of SSI (ciNPWT, 4.49% [95% confidence interval (CI), 2.48-8.00] vs. control, 11.32% [95% CI, 7.51-16.70]; P = 0.0103) was significantly lower for patients treated with ciNPWT. A fixed-effects model showed no significant difference between patients who received ciNWPT or a standard postoperative dressing with respect to requiring reoperations for wound debridement (odds ratio, 1.25; 95% CI, 0.64-2.41). In addition, wound dehiscence was not significantly different between the 2 groups, although it was nonsignificantly lower in ciNWPT-treated patients (ciNPWT, 4.59% [95% CI, 2.49-8.31] vs. control: 7.48% [95% CI, 4.38-12.47]; P = 0.23)., Conclusions: ciNPWT may reduce the rates of SSI after spinal fusion. The use of ciNWPT may also significantly reduce the burden associated with postoperative wound complications, but the meta-analysis was insufficiently powered to make this association. Additional studies may identify a subset of patients who benefit from ciNPWT for other wound-related complications., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To identify risk factors for development of deep venous thrombosis (DVT) in patients undergoing spinal irrigation and débridement for an infection with subsequent peripherally inserted central catheter placement and to determine if chemoprophylaxis mitigates the risk of developing DVT., Methods: Patients with spinal infection and peripherally inserted central catheter placement at an academic medical center between 2009 and 2020 were retrospectively identified. Patients were grouped based on whether they had postoperative DVT. Preoperative, intraoperative, and postoperative variables were compared to determine their association with postoperative DVT. A multivariate logistic regression model was developed to measure the effect of postoperative DVT chemoprophylaxis on the likelihood of DVT development., Results: Of 335 patients included in the analysis, 48 (14.3%) developed DVT, and 287 (85.7%) did not develop DVT. Patients who developed DVT had a greater number of irrigation and débridement procedures (1.90 ± 1.49 vs. 1.44 ± 0.86, P = 0.024). Multivariate logistic regression analysis identified a history of diabetes (odds ratio [OR] = 2.23; 95% confidence interval [CI], 1.01-4.92; P = 0.045), DVT/pulmonary embolism (OR = 4.49; 95% CI, 1.93-10.34; P < 0.001), and number of irrigation and débridement procedures (OR = 1.51; 95% CI, 1.13-2.06; P = 0.006) as significant positive predictors of postoperative DVT. Chemoprophylaxis (OR = 0.68; 95% CI, 0.32-1.45; P = 0.324) was not a significant negative predictor of postoperative DVT., Conclusions: Patients undergoing spinal débridement with subsequent peripherally inserted central catheter placement are at high risk for postoperative DVT. Multiple spine débridement procedures, a history of diabetes, and previous DVT are risk factors for postoperative DVT. Chemoprophylaxis does not mitigate patients' risk for postoperative DVT., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: The Orthopaedic In-Training Examination (OITE) is an important metric for orthopaedic residents and residency programs to gauge a resident's orthopaedic knowledge. Because the OITE is correlated with the likelihood of passing part I of the American Board of Orthopaedic Surgery, greater emphasis is being placed on the examination. However, a detailed look at the questions most likely to appear on the spine subsection of the OITE has not been done in the past decade., Methods: Digital copies of the OITEs during the years 2017 through 2021 were obtained online through the "ResStudy" program within the American Academy of Orthopaedic Surgeons Online Learning Platform. All spine-related questions were categorized into five different categories including type of spine question (knowledge-based, diagnosis, or evaluation/management), anatomical region, imaging modality provided, subject matter, and referenced journal or textbook. The total number and likelihood of each question type to appear on the OITE were defined as mean and percentage of the total number of spine questions, respectively., Results: A total of 139 spine questions were identified on the OITE during the years 2017 to 2021. The most common type of spine questions were evaluation/management (N = 65) and knowledge-based questions. We identified lumbar (N = 45), cervical (N = 42), thoracolumbar (N = 13), and thoracic (N = 12) as the most commonly tested anatomical regions. Spinal trauma (N = 26), disk disease/disk herniation (N = 16), postoperative complications (N = 15), and scoliosis/sagittal balance (N = 15) were the most commonly tested material. Spine (N = 54) was almost two times more likely to be referenced as the source for the tested material compared with other journals or textbooks., Conclusions: Understanding the spine topics most likely to appear on the OITE may allow orthopaedic residents and residency programs to supplement educational objectives toward the highest yield spine topics and journals., (Copyright © 2022 by the American Academy of Orthopaedic Surgeons.)

Study Design: A retrospective cohort study., Objective: To determine if (1) preoperative marijuana use increased complications, readmission, or reoperation rates following anterior cervical discectomy and fusion (ACDF), (2) identify if preoperative marijuana use resulted in worse patient-reported outcome measures (PROMs), and (3) investigate if preoperative marijuana use affects the quantity of opioid prescriptions in the perioperative period., Summary of Background Data: A growing number of states have legalized recreational and/or medical marijuana, thus increasing the number of patients who report preoperative marijuana use. The effects of marijuana on clinical outcomes and PROMs in the postoperative period are unknown., Methods: All patients 18 years of age and older who underwent primary one- to four-level ACDF with preoperative marijuana use at our academic institution were retrospectively identified. A 3:1 propensity match was conducted to compare patients who used marijuana versus those who did not. Patient demographics, surgical characteristics, clinical outcomes, and PROMs were compared between groups. Multivariate regression models measured the effect of marijuana use on the likelihood of requiring a reoperation and whether marijuana use predicted inferior PROM improvements at the one-year postoperative period., Results: Of the 240 patients included, 60 (25.0%) used marijuana preoperatively. Multivariate logistic regression analysis identified marijuana use (odds ratio=5.62, P <0.001) as a predictor of a cervical spine reoperation after ACDF. Patients who used marijuana preoperatively had worse one-year postoperative Physical Component Scores of the Short-Form 12 (PCS-12) ( P =0.001), Neck Disability Index ( P =0.003), Visual Analogue Scale (VAS) Arm ( P =0.044) and VAS Neck ( P =0.012). Multivariate linear regression found preoperative marijuana use did not independently predict improvement in PCS-12 (β=-4.62, P =0.096), Neck Disability Index (β=9.51, P =0.062), Mental Component Scores of the Short-Form 12 (MCS-12) (β=-1.16, P =0.694), VAS Arm (β=0.06, P =0.944), or VAS Neck (β=-0.44, P =0.617)., Conclusion: Preoperative marijuana use increased the risk of a cervical spine reoperation after ACDF, but it did not significantly change the amount of postoperative opioids used or the magnitude of improvement in PROMs., Level of Evidence: Levwl III., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: This is a retrospective cohort study., Objective: The aim was to evaluate differences in readmission rates, number of debridements, and length of antibiotic therapy when comparing bacterial gram type following lumbar spinal fusion infections., Summary of Background Data: Surgical site infections (SSIs) after spinal fusion serve as a significant source of patient morbidity. It remains to be elucidated how bacterial classification of the infecting organism affects the management of postoperative spinal SSI., Methods: Patients who underwent spinal fusion with a subsequent diagnosis of SSI between 2013 and 2019 were retrospectively identified. Patients were grouped based on bacterial infection type (gram-positive, gram-negative, or mixed infections). Poisson regressions analyzed the relationship between the type of bacterial infection and the number of irrigation and debridement (I&D) reoperations, and the duration of intravenous (IV) antibiotic therapy. Significance was set at P <0.05., Results: Of 190 patients, 92 had gram-positive (G+) infections, 57 had gram-negative (G-) infections, and 33 had mixed (M) infections. There was no difference in 30 or 90-day readmissions for infection between groups (both P =0.051). Patients in the M group had longer durations of IV antibiotic treatment (G+: 46.4 vs. G-: 41.0 vs. M: 55.9 d, P =0.002). Regression analysis demonstrated mixed infections were 46% more likely to require a greater number of debridements ( P =0.001) and 18% more likely to require an increased duration of IV antibiotic therapy ( P <0.001), while gram-negative infections were 10% less likely to require an increased duration of IV antibiotic therapy ( P <0.001) when compared with G- infections., Conclusion: Spinal SSI due to a mixed bacterial gram type results in an increased number of debridements and a longer duration of IV antibiotics required to resolve the infection compared with gram-negative or gram-positive infections., Level of Evidence: Level III., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To determine if postoperative soft cervical orthosis use affects arthrodesis rates on a per-level or construct basis after 1-level and 2-level anterior cervical discectomy and fusion (ACDF)., Methods: Electronic medical records were queried for 1-level and 2-level primary ACDF between 2016 and 2019 at a single academic center. Surgeons prescribed either a soft cervical orthosis or no orthosis. Pseudarthrosis rates were evaluated by dynamic cervical spine radiographs with arthrodesis defined by <1 mm of interspinous motion. Continuous and categorical data were compared using analysis of variance or χ 2 tests. Multivariate logistic regression analysis was used to examine independent predictors of pseudarthrosis., Results: A total of 316 unique patients (504 instrumented levels) met the inclusion criteria. Eighty-four percent of patients were prescribed a soft cervical orthosis. Overall, arthrodesis occurred at 344 (80.9%) and 62 (78%) levels in patients with and without cervical orthosis, respectively. When evaluating patients placed in a cervical orthosis versus those who were not, there were no differences in pseudarthrosis or revision rates. Further, there were no differences in pseudarthrosis on a per-level basis. Further, cervical orthosis use was not an independent predictor of pseudarthrosis (odds ratio, 0.86; 95% confidence interval, 0.47-1.57; P =0.623) on multivariate analysis., Conclusions: Postoperative placement of soft cervical orthoses after 1-level or 2-level ACDF was not associated with improved arthrodesis or reduced rate of revision surgery., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background Context: Postoperative dynamic radiographs are used to assess fusion status after anterior cervical discectomy and fusion (ACDF) with comparable accuracy to computed tomography (CT) scans., Purpose: To (1) determine if dynamic radiographs accurately predict pseudarthrosis revision in a cohort of largely asymptomatic patients who underwent ACDF, (2) determine how adjacent segment motion is affected by fusion status, and (3) analyze how clinical outcomes differ between patients with symptomatic and asymptomatic pseudarthrosis., Study Design: Retrospective cohort study., Patient Sample: Patients ≥ 18 years who underwent primary one- to four-level ACDF at a single institution over a 10-year period., Outcome Measures: Interspinous motion on preoperative and postoperative flexion-extension radiographs and preoperative and postoperative Visual Analogue Scale for Neck Pain (VAS Neck) and Arm Pain (VAS Arm), Neck Disability Index (NDI), Modified Japanese Orthopaedic Association scale (mJOA), Mental and Physical Component Scores of the Short-Form 12 (SF-12) Health Survey (MCS-12 and PCS-12) METHODS: The difference in spinous process motion between flexion and extension radiographs was used to determine motion at each level of the ACDF construct. Pseudarthrosis was defined as ≥ 1 mm spinous process motion on dynamic radiographs. A receiver operating characteristic (ROC) curve was generated to predict the probability of surgical revision for pseudarthrosis based on millimeters of interspinous motion at each instrumented level. Patient reported outcome measures (PROMs) were used to assess the effect of pseudarthrosis on clinical outcomes. Alpha was set at p<.05., Results: A total of 597 patients met inclusion criteria including 1,203 ACDF levels. Of those, 215 patients (36.0%) were diagnosed with a pseudarthrosis on dynamic radiographs with 29 patients (4.9%) requiring pseudarthrosis revision. ROC analysis identified a "cutoff" value of 1.00 mm of interspinous process motion for generating an optimal area under the curve (AUC). The negative predictive value (NPV) was 99.6%, whereas the positive predictive value (PPV) was 13.7%. When analyzing adjacent segment motion, the Δ supra-adjacent interspinous process motion (ISM) was significantly lower for patients with a superior construct pseudarthrosis (-1.06 mm vs. 1.80 mm, p<.001), whereas the Δ infra-adjacent level ISM was significantly lower for patients with an inferior construct pseudarthrosis (-1.21 mm vs. 2.15 mm, p<.001). Patients with a pseudarthrosis not requiring revision had worse postoperative NDI (29.3 vs. 23.4, p=.027), VAS Neck (3.40 vs. 2.63, p=.012), and VAS Arm (3.09 vs. 1.85, p=.001) scores at 3 months, but not 1-year, compared with patients who were fused. Patients requiring pseudarthrosis revision had higher 1-year postoperative NDI (38.0 vs. 23.7, p=.047) and lower 1-year postoperative Δ VAS Arm (-0.22 vs. -2.97, p=.016) scores., Conclusions: One-year postoperative dynamic radiographs have a greater than 99% negative predictive value for identifying patients requiring pseudarthrosis revision, but they have a low positive predictive value. Most patients with a pseudarthrosis remain asymptomatic with similar 1-year postoperative patient-reported outcomes compared with patients without a pseudarthrosis., Competing Interests: Declarations of competing interests The authors, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article. There are no relevant disclosures., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: The purpose of this retrospective cohort study was to evaluate the effect of tranexamic acid (TXA) on reducing perioperative blood loss and length of stay after transforaminal lumbar interbody fusion (TLIF). Spine surgery is associated with the potential for significant blood loss, and adequate hemostasis is essential to visualizing crucial structures during the approach and procedure. Although TXA use has been extensively studied in the pediatric and adult spinal deformity literature, there is a dearth of literature on its efficacy in reducing blood loss for patients who undergo 1- to 3-level TLIF., Methods: All patients requiring 1- to 3-level TLIF who received a preoperative loading dose of TXA were grouped and compared with patients who didn't receive TXA. Demographic, surgical, and laboratory values were collected and analyzed. Continuous and categorical variables were analyzed with χ 2 , Kruskal-Wallis, or analysis of variance tests, depending on normality and data type. Multiple linear regressions were developed to determine independent predictors of the estimated blood loss (EBL), total blood loss, drain output, and length of stay. Statistical significance was set at P < 0.05., Results: Patients who received preoperative TXA had more comorbidities (P = 0.006), longer surgery length (P < 0.001), and longer length of stay (P = 0.004). TXA was independently associated with a decreased day 0, 1, 2, and total drain output (P < 0.001, P = 0.001, P = 0.007, P < 0.001, respectively), but was not associated with a change in EBL, total blood loss, or length of stay., Conclusions: The application of preoperative TXA for patients undergoing 1- to 3-level TLIF reduced drain output in the first 2 postoperative days, but it did not affect hospital length of stay, total blood loss, or EBL., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Study Design: This was a retrospective cohort study., Objective: The objective of this study was to compare radiographic and patient-reported outcome measures (PROMs) between circumferential fusions and transforaminal lumbar interbody fusion (TLIF) for adult isthmic spondylolisthesis (IS)., Summary of Background Data: Definitive management of adult IS typically requires decompression and fusion. Multiple fusion techniques have been described, but literature is sparse in identifying the optimal technique., Methods: Patients with IS undergoing single-level or 2-level circumferential fusion or TLIF with a minimum 1-year follow-up were included. Patient demographics, surgical characteristics, and PROMs were extracted from patients' electronic medical records. Descriptive statistics and multivariate regression analysis compared outcomes with significance set at P -value &lt;0.05., Results: A total of 78 circumferential fusions (48 open decompression and fusions and 30 circumferential fusions utilizing posterior percutaneous instrumentation) and 50 TLIF procedures were included. Length of stay was significantly longer when comparing circumferential procedures (3.56±0.96 d) versus TLIFs (2.88±1.14 d) ( P =0.002). The circumferential fusion group resulted in greater postoperative improvement in segmental lordosis [anterior/posterior (A/P): 6.45, TLIF: -1.99, P &lt;0.001], posterior disk height (A/P: 12.6 mm, TLIF: 8.9 mm, P &lt;0.001), and ∆disk height (A/P: 7.7 mm, TLIF: 3.6 mm, P &lt;0.001). Both groups significantly improved in all PROMs ( P &lt;0.001). While the circumferential fusion group had a significantly higher rate of perioperative surgical complications (12.82% vs. 2.00%, P =0.049), there was no difference in the rate of 30-day readmissions ( P =0.520) or revision surgeries between techniques ( P =0.057)., Conclusions: Circumferential fusions are associated with improvements in radiographic outcomes compared with TLIFs, but this is at the expense of longer hospital length of stay and increased risk for perioperative complications. The surgical technique did not result in superior postoperative PROMs or differences in readmissions or revisions., Competing Interests: Dr Schroeder has received funds to travel from AOSpine and Medtronic. Dr Vaccaro has consulted or has done independent contracting for DePuy, Medtronic, Stryker Spine, Globus, Stout Medical, Gerson Lehrman Group, Guidepoint Global, Medacorp, Innovative Surgical Design, Orthobullets, Ellipse, and Vertex. He has also served on the scientific advisory board/board of directors/committees for Flagship Surgical, AO Spine, Innovative Surgical Design, and Association of Collaborative Spine Research. Dr Vaccaro has received royalty payments from Medtronic, Stryker Spine, Globus, Aesculap, Thieme, Jaypee, Elsevier, and Taylor Francis/Hodder and Stoughton. He has stock/stock option ownership interests in Replication Medica, Globus, Paradigm Spine, Stout Medical, Progressive Spinal Technologies, Advanced Spinal Intellectual Properties, Spine Medica, Computational Biodynamics, Spinology, In Vivo, Flagship Surgical, Cytonics, Bonovo Orthopaedics, Electrocore, Gamma Spine, Location Based Intelligence, FlowPharma, R.S.I., Rothman Institute and Related Properties, Innovative Surgical Design, and Avaz Surgical. In addition, Dr Vaccaro has also provided expert testimony. He has also served as deputy editor/editor of Clinical Spine Surgery. The remaining authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: For patients with cervical and thoracolumbar AO Spine type C injuries, the authors sought to 1) identify whether preoperative vertebral column translation is predictive of a complete spinal cord injury (SCI) and 2) identify whether preoperative or postoperative vertebral column translation is predictive of neurological improvement after surgical decompression., Methods: All patients who underwent operative treatment for cervical and thoracolumbar AO Spine type C injuries at the authors' institution between 2006 and 2021 were identified. CT and MRI were utilized to measure vertebral column translation in millimeters prior to and after surgery. A receiver operating characteristic (ROC) curve was generated to predict the probability of sustaining a complete SCI on the basis of the amount of preoperative vertebral column translation. ROC curves were then used to predict the probability of neurological recovery on the basis of preoperative and postoperative vertebral column translation., Results: ROC analysis of 67 patients identified 6.10 mm (area under the curve [AUC] 0.77, 95% CI 0.650-0.892) of preoperative vertebral column translation as predictive of complete SCI. Additionally, ROC curve analysis found that 10.4 mm (AUC 0.654, 95% CI 0.421-0.887) of preoperative vertebral column translation was strongly predictive of no postoperative neurological improvement. Residual postoperative vertebral column translation after fracture reduction and instrumentation had no predictive value on neurological recovery (AUC 0.408, 95% CI 0.195-0.622)., Conclusions: For patients with cervical and thoracolumbar AO Spine type C injuries, the amount of preoperative vertebral column translation is highly predictive of complete SCI and the likelihood of postoperative neurological recovery.

Objective: 1) To analyze the effect of operative sequence (anterior cervical discectomy and fusion [ACDF] first or rotator cuff repair [RCR] first) on surgical outcomes after both procedures for patients with dual shoulder-spine injuries and 2) to determine how operative sequence affects patient-reported outcome measures (PROMs) after surgery., Methods: Patients >18 years of age who underwent primary ACDF and primary RCR at our institution were retrospectively identified. Only patients with overlapping symptoms before the first procedure were included. Patients were divided into 2 cohorts (ACDF first or RCR first). Patient demographics, surgical characteristics, surgical outcomes, and PROMs were compared between groups. Multivariate linear regression models were developed to determine if operative order was predictive of improvements in PROM scores at the 1-year postoperative point after the second procedure. Alpha was set at P < 0.05., Results: Of the 85 patients included, 44 patients (51.8%) underwent ACDF first, whereas 41 patients (48.2%) underwent RCR first. There were no significant differences in the rate of 90-day readmission, spine reoperations, and rotator cuff reoperations between groups (all, P > 0.05). Multivariate linear regression showed that undergoing an ACDF first was not a significant predictor of Δ Mental Component Score of the Short-Form 12 (β = -2.78; P = 0.626) and Δ Physical Component Score of the Short-Form 12 (β = 7.74; P = 0.077) at the 1-year postoperative point after the second procedure., Conclusions: For patients with dual shoulder-spine injuries who are appropriate surgical candidates, undergoing ACDF first compared with RCR first does not result in significant differences in clinical surgical or patient-reported outcomes., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Context: Abdominal pain after surgery can occur for numerous reasons. Postoperative radiographs may be indicated to evaluate for ileus or other reasons for the pain. Whether outcomes are significantly different based on whether patients get radiographs following lateral lumbar interbody fusion (LLIF) are unclear., Aims: To investigate the postoperative outcomes of patients experiencing abdominal pain after LLIF., Settings and Design: This retrospective cohort study included patients at a tertiary academic medical center and surrounding affiliated hospitals., Materials and Methods: Patients >18 years of age who underwent elective LLIF at a single institution were retrospectively identified. Patients were stratified into two groups depending on whether they received a postoperative abdominal radiograph or computed tomography (CT) scan for postoperative abdominal pain., Statistical Analysis: Patient demographics, surgical characteristics, and surgical outcomes were compared between groups utilizing independent t -tests or Mann-Whitney U -tests for continuous variables or Pearson's Chi-square tests for categorical variables., Results: A total of 153 patients (18 with abdominal scans, 135 without) were included. Patients who received a postoperative abdominal radiograph or CT scan were more likely to undergo exploratory laparotomy (11.1% vs. 0.00%, P = 0.013). Ultimately, patients with abdominal scans had a longer hospital length of stay (6.67 vs. 3.79 days, P = 0.002) and were discharged home less frequently (71.4% vs. 83.7%, P = 0.002)., Conclusions: Patients who received abdominal imaging after LLIF were more likely to undergo exploratory laparotomy, experience longer hospital length of stay, and were discharged home less frequently. Intra-abdominal air on postoperative imaging without corresponding physical exam findings consistent with bowel injury is not an appropriate indication for surgical intervention., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Craniovertebral Junction and Spine.)

Objective: To determine the influence of preoperative workers' compensation (WC) status on patient-reported outcome measures following lumbar decompression with or without fusion., Methods: All patients undergoing lumbar decompression with or without fusion at a single academic institution between 2013 and 2017 were identified. Patients were split into groups based on WC status: no workers' compensation (NWC), WC), or retired. Intragroup analysis used paired t tests. Outcomes between groups were compared using Kruskal-Wallis H test. Multiple linear regression analysis determined if WC status was a predictor of change in patient-reported outcome measures. Subgroup analysis was conducted for WC patients who returned to work., Results: Of 571 included patients, 242 (43.4%) had NWC, 83 (14.5%) had WC, and 246 (43.1%) were retired. Comparing within groups, WC patients showed significant improvement in Short Form-12 Health Survey Physical Component Score, Oswestry Disability Index, visual analog scale (VAS) back pain, and VAS leg pain (all P < 0.001) after surgery. However, WC patients improved less than NWC or retired patients in Short Form-12 Health Survey Physical Component Score (P = 0.010), VAS back pain (P = 0.028), and VAS leg pain (P = 0.015). WC was an independent predictor of decreased improvement in Short Form-12 Health Survey Physical Component Score (β = -4.31, P = 0.001), VAS back pain (β = 0.90, P = 0.034), and VAS leg pain (β = 1.50, P = 0.002) on multivariate analysis. WC patients who did not return to work was an independent predictor of decreased improvement in VAS back pain (β = 1.39, P = 0.016) and VAS leg pain (β = 2.11, P = 0.001)., Conclusions: WC patients improve less than NWC patients. However, WC patients who return to work have similar VAS back and neck pain improvements as NWC patients., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Study Design: Retrospective cohort study., Objective: The objective of this study is to determine the effect of focal lordosis and global alignment and proportion (GAP) scores on patient reported outcome measures (PROMs) after posterior lumbar fusion for patients with 1- or 2-level lumbar degenerative spondylolisthesis (DS)., Summary of Background Data: In patients with DS, improvements in spinopelvic parameters are believed to improve clinical outcomes. However, the effect of changing focal lordosis in patients with 1-or 2-level degenerative lumbar spondylolisthesis is unclear., Materials and Methods: Postoperative spinopelvic parameters and perioperative focal lordosis changes were measured for 162 patients at a single academic center from January 2013 to December 2017. Patients were divided into three groups: >2° (lordotic group), between 2° and -2° (neutral group), and -2°° (kyphotic group). Patients were then reclassified based on GAP scores. Recovery ratios (RR) and the number of patients achieving the minimal clinically important difference (MCID) were calculated for PROMs. Standard descriptive statistics were reported for patient demographics and outcomes data. Multiple linear regression analysis controlled for confounders. Alpha was set at P < 0.05., Results: There was no significant association between change in focal lordosis and surgical complications including adjacent segment disease ( P = 0.282), instrumentation failure ( P = 0.196), pseudarthrosis ( P = 0.623), or revision surgery ( P = 0.424). In addition, the only PROM affected by change in focal lordosis was Mental Component Scores (ΔMCS-12) (lordotic = 2.5, neutral = 8.54, and kyphotic = 5.96, P = 0.017) and RR for MCS-12 (lordotic = 0.02, neutral = 0.14, kyphotic 0.10, P = 0.008). Linear regression analysis demonstrated focal lordosis was a predictor of decreased improvement in MCS-12 (β = -6.45 [-11.03- -1.83], P = 0.007). GAP scores suggested patients who were correctly proportioned had worse MCID compared to moderately disproportioned and severely disproportioned patients ( P = 0.024)., Conclusions: The change in focal lordosis not a significant predictor of change in PROMs for disability, pain, or physical function. Proportioned patients based on the GAP score had worse MCID for Oswestry Disability Index., Level of Evidence: III., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Craniovertebral Junction and Spine.)

Brd2 belongs to the BET family of epigenetic transcriptional co-regulators that act as adaptor-scaffolds for the assembly of chromatin-modifying complexes and other factors at target gene promoters. Brd2 is a protooncogene and candidate gene for juvenile myoclonic epilepsy in humans, a homeobox gene regulator in Drosophila, and a maternal-zygotic factor and cell death modulator that is necessary for normal development of the vertebrate central nervous system (CNS). As two copies of Brd2 exist in zebrafish, we use antisense morpholino knockdown to probe the role of paralog Brd2b, as a comparative study to Brd2a, the ortholog of human Brd2. A deficiency in either paralog results in excess cell death and dysmorphology of the CNS, whereas only Brd2b deficiency leads to loss of circulation and occlusion of the pronephric duct. Co-knockdown of both paralogs suppresses single morphant defects, while co-injection of morpholinos with paralogous RNA enhances them, suggesting novel genetic interaction with functional antagonism. Brd2 diversification includes paralog-specific RNA variants, a distinct localization of maternal factors, and shared and unique spatiotemporal expression, providing unique insight into the evolution and potential functions of this gene.

With mounting time on continuous-flow left ventricular assist device (CF-LVAD) support, patients occasionally sustain damage to the device driveline. Outcomes associated with external and internal driveline damage and repair are currently not well documented. We sought to evaluate the outcomes of driveline damage and its repair. Electronic search was performed to identify all relevant studies published over the past 20 years. Fifteen studies were selected for analysis comprising of 55 patients with CF-LVAD dysfunction due to driveline damage. Demographic and perioperative variables along with outcomes including survival rates were extracted and pooled for the systematic review. Most patients (53/55) were supported on HeartMate II LVAD (Abbott Laboratories, Abbott Park, IL). Internal damage was more commonly reported than external damage [69.1% (38/55) vs. 30.9% (17/55), P = .01]. Median time to driveline damage was 1.9 years [IQR 1.0, 2.5]. Most patients presented with a CF-LVAD alarm [94.5% (52/55)] and patients with internal driveline damage had a significantly higher rate of alarm activation compared to that observed for those with external damage [38/38 (100%) vs. 14/17 (82.4%), P = .04]. Patients with internal driveline dysfunction were more likely to experience component wear compared to those with external driveline dysfunction [10/38 (26.3%) vs. 0/17 (0%), P = .05]; 14.5% of patients (8/55) underwent external repair of the driveline, 5.5% (3/55) were treated with rescue tape, and 5.5% (3/55) were placed on an ungrounded cable, indicating a short-to-shield event had occurred. A total of 49.1% of patients (27/55) underwent CF-LVAD exchange, 5.5% (3/55) were weaned off the CF-LVAD to explant, and 5.5% (3/55) underwent emergent heart transplantation. The median length of hospital stay was 12 days [IQR 7, 12] and 30-day mortality rate was 14.5% (8/55). Driveline damage was more commonly reported at an internal location and despite being a well-recognized complication, mortality still appears high., (© 2021 International Center for Artificial Organs and Transplantation and Wiley Periodicals LLC.)

Background: Acute pulmonary embolism (PE) is associated with significant mortality. Surgical embolectomy is a viable treatment option; however, it remains controversial as a result of variable outcomes. This review investigates patient outcomes after surgical embolectomy for acute PE., Methods: An electronic search was performed to identify articles reporting surgical embolectomy for treatment of PE. 32 studies were included comprising 936 patients. Demographic, perioperative, and outcome data were extracted and pooled for systematic review., Results: Mean patient age was 56.3 years (95% confidence interval [CI], 52.5, 60.1), and 50% were male (95% CI, 46, 55); 82% had right ventricular dysfunction (95% CI, 62, 93), 80% (95% CI, 67, 89) had unstable hemodynamics, and 9% (95% CI, 5, 16) experienced cardiac arrest. Massive PE and submassive PE were present in 83% (95% CI, 43, 97)] and 13% (95% CI, 2, 56) of patients, respectively. Before embolectomy, 33% of patients (95% CI, 14, 60) underwent systemic thrombolysis, and 14% (95% CI, 8, 24) underwent catheter embolectomy. Preoperatively, 47% of patients were ventilated (95% CI, 26; 70), and 36% had percutaneous cardiopulmonary support (95% CI, 11, 71). Mean operative time and mean cardiopulmonary bypass time were 170 minutes (95% CI, 101, 239) and 56 minutes (95% CI, 42, 70), respectively. Intraoperative mortality was 4% (95% CI, 2, 8). Mean hospital and intensive care unit stay were 10 days (95% CI, 6, 14) and 2 days (95% CI, 1, 3), respectively. Mean postoperative systolic pulmonary artery pressure (sPAP) was significantly decreased from the preoperative period (sPAP 57.8, mm Hg; 95% CI, 53, 62.7) to the postoperative period (sPAP, 31.3 mm Hg; 24.9, 37.8); P < .01). In-hospital mortality was 16% (95% CI, 12, 21). Overall survival at 5 years was 73% (95% CI, 64, 81)., Conclusions: Surgical embolectomy is an acceptable treatment option with favorable outcomes., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Massive pulmonary embolism (PE) can cause hemodynamic instability leading to high mortality. Extracorporeal life support (ECLS) has been increasingly used as a bridge to definitive therapy. This systematic review investigates the outcomes of ECLS for the treatment of massive PE., Methods: Electronic search was performed to identify all relevant studies published on ECLS use in patients with PE. 50 case series or reports were selected comprising 128 patients with acute massive PE who required ECLS. Patient-level data were extracted for statistical analysis., Results: Median patient age was 50 [36, 63] years and 41.3% (50/121) were male. 67.2% (86/128) of patients presented with cardiac arrest. Median heart rate was 126 [118, 135] and median systolic pulmonary artery pressure (sPAP) was 55 [48, 69] mmHg. The majority of ECLS included veno-arterial ECLS [97.1% (99/102)]. Median ECLS time was 3 [2, 6] days. 43.0% (55/128) patients received systemic thrombolysis, 22.7% (29/128), received catheter-guided thrombolysis, and 37.5% (48/128) underwent surgical embolectomy. 85.1% (97/114) were weaned off ECLS. Post-ECLS complications included bleeding in 23.4% (30/128), acute renal failure in 8.6% (11/128), dialysis in 6.3% (8/128), heparin-induced thrombocytopenia in 3.1 (4/128), and extremity hypoperfusion in 2.3% (3/128). The most common cause of death was shock at 30.3% (10/33). The median length of hospital stay was 22 [11, 39] days including 8 [5, 13] intensive care unit (ICU) days. The 30-day mortality rate was 22% (20/91)., Conclusions: ECLS is safe and effective therapy in unstable patients with acute massive pulmonary embolism and offers acceptable outcomes., (Copyright © 2019. Published by Elsevier B.V.)

Objective: This study was conducted to screen scrotal hernia in domesticated swine from selected breeders in the Philippines. This defect is associated with a cytosine to thymine mutation in the BCL-2 associated X protein ( BAX ) gene of swine., Methods: Genetic screening was done by DNA extraction followed by amplification and digestion using polymerase chain reaction-restriction fragment length polymorphism, amplifying the 416 bp region of the BAX gene that was subjected to digestion using the Ear I enzyme. Sequencing was also conducted to validate the results., Results: Results revealed that out of 538 samples tested, 411 (76.4%) of the samples were found to be normal whereas the remaining were carriers of the mutation in which 80 (14.9%) were heterozygous mutants and 47 (8.7%) were homozygous mutants. Pietrain breed was found to have the highest incidence., Conclusion: Having a scrotal hernia eliminates the chances of using the boar as a breeder stock because the following generations arising from it would most likely exhibit herniation. It is therefore advised to establish a genetic screening method for Scrotal Hernia in the Philippines to eliminate the negative gene from the herd.