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To characterize the volume dependence of both facilities and surgeons on postoperative complications after lumbar fusion and characterize the role of socioeconomic status.Adults who underwent lumbar fusion from 2011 to 2015 were identified using International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes for lumbar disc degeneration or spondylolisthesis and procedure codes for lumbar fusion in the New York Statewide Planning and Research Cooperative System database. Complications were compared across surgeon and facility volumes using multivariable Cox proportional hazards regression, controlling for patient demographic and clinical factors. Surgeon and facility volumes were compared between the lowest and highest 20%.Of the 26,211 patients identified with a lumbar fusion, 16,377 patients were treated at a high-volume or low-volume facility or by a high-volume or low-volume surgeon. Low-volume facilities had higher 3-month and 12-month rates of readmission, pneumonia, and cellulitis; lower 1-month, 3-month, and 12-month rates of deep vein thrombosis; and lower 1-month rates of wound complications. Low-volume surgeons had higher 1-month, 3-month, and 12-month rates of readmission, acute renal failure, surgical site infection, and wound complications; high 1-month and 3-month rates of urinary tract infection and pulmonary embolism; and a lower 12-month rate of revision. Patients who were treated by low-volume surgeons and had complications were more concentrated to ZIP codes with high social deprivation.Both high-volume facilities and high-volume surgeons show lower rates of complications and readmission. There are significant socioeconomic disparities regarding which patients can access high-volume surgeons.

Background Ewing Sarcoma (ES) is an aggressive tumor affecting adolescents and young adults. Prior studies investigated the association between rurality and outcomes, although there is a paucity of literature focusing on ES. Objective This study aims to determine whether ES patients in rural areas are subject to adverse outcomes. Methods This study utilized the Surveillance, Epidemiology, and End Results (SEER) database. A Poisson regression model was used with controls for race, sex, median county income, and age to determine the association between rurality and tumor size. A multivariate Cox Proportional Hazard Model was utilized, controlling for age, race, gender, income, and tumor size. Results There were 868 patients eligible for analysis, with a mean age of 14.14 years. Of these patients, 97 lived in rural counties (11.18%). Metropolitan areas had a 9.50% smaller tumor size (p Conclusion Patients in metropolitan areas had a smaller tumor size at time of diagnosis and had a more favorable survival rate for cancer-specific mortality compared to patients residing in rural areas. Further work is needed to examine interventions to reduce this discrepancy and investigate the effect of extremely rural and urban settings and why racial disparities occur.

Cauda equina syndrome is a potentially devastating spinal condition. The diagnosis of cauda equina syndrome lacks sensitivity and specificity, sometimes occurring after irreparable neurological damage has happened. Timely diagnosis and treatment is imperative for optimal outcomes and for avoiding medicolegal ramifications. Cauda equina syndrome results from conditions that compress the nerves in the lumbosacral spinal canal. Although no consensus definition exists, it generally presents with varying degrees of sensory loss, motor weakness, and bowel and bladder dysfunction (the latter of which is required to definitively establish the diagnosis). A thorough history and physical exam is imperative, followed by magnetic resonance or computed tomography imaging myelogram to aid in diagnosis and treatment. Once suspected, emergent spinal surgery referral is indicated, along with urgent decompression. Even with expeditious surgery, improvements remain inconsistent. However, early intervention has been shown to portend greater chance of neurologic recovery. All providers in clinical practice must understand the severity of this condition. Providers can optimize long-term patient outcomes and minimize the risk of litigation by open communication, good clinical practice, thorough documentation, and expeditious care.

Three-column osteotomy (3-CO) is a powerful tool for spinal deformity correction but has been associated with substantial risk and surgical invasiveness. It is incompletely understood how frailty might affect patients undergoing 3-CO.The PearlDiver database was used to examine spinal deformity patients with a diagnosis of frailty who had undergone 3-CO. Frail and nonfrail patients were matched, and the revision surgery rates, complications, and hospitalization costs were calculated. Logistic regression was used to account for possible confounding variables. Of the 2871 included patients, 1460 had had frailty and 1411 had had no frailty.The frail patients were older, had had more comorbidities (P0.001), and were more likely to have undergone posterior interbody fusion (P0.05), without differences in the anterior interbody fusion rates. No differences were found in the reoperation rates for ≤5 years. At 30 days, the frail patients were more likely to have experienced acute kidney injury (P = 0.018), bowel/bladder dysfunction (P = 0.014), cardiac complications (P = 0.006), and pneumonia (P = 0.039). At 2 years, the frail patients were also more likely to have experienced bowel/bladder dysfunction (P = 0.028), cardiac complications (P 0.001), deep vein thrombosis (P = 0.027), and sepsis (P = 0.033). The cost for the procedures was also higher for the frail patients than for the nonfrail patients ($24,544.79 vs. $21,565.63; P = 0.043).We found that frail patients undergoing 3-CO were more likely to experience certain medical complications and had had higher associated costs but similar reoperation rates compared with nonfrail patients. Careful patient selection and surgical strategy modification might alter the risks of medical and surgical complications after 3-CO for frail patients.

BACKGROUND Academic surgeons are invaluable for scientific advancement and training the next generation of orthopedic surgeons. OBJECTIVE This study aimed to describe a cohort of academic orthopedic surgeons currently in practice with common academic metrics. METHODS ACGME-accredited orthopedic surgery programs with a university affiliation were identified. The primary independent variable in this study was formal research training as defined by a research fellowship or attainment of a PhD. Outcomes included academic rank, h-index attained, number of publications, and funding by the National Institutes of Health (NIH). RESULTS 1641 orthopedic surgeons were identified across 73 programs. 116 surgeons (7.07%) received formal academic research training. The academic training group and non-academic training group had a similar completion rate of clinical fellowship programs (93.97% vs 93.77%, p=0.933), attainment of other advanced degrees (10.34% vs 8.46%, p=0.485), and years since completion of training (17.49-years vs 16.28-years, p=0.284). Surgeons completing academic research training had a significantly higher h-index (18.46 vs 10.88, p CONCLUSION Formalized research training, either as a research fellowship or PhD, is associated with an increased h-index and likelihood of NIH funding, although this association was not found for academic rank after adjusted regression analysis.

Background Readmission after spine surgery is costly and a relatively common occurrence. Previous research identified several risk factors for readmission; however, the conclusions remain equivocal. Machine learning algorithms offer a unique perspective in analysis of risk factors for readmission and can help predict the likelihood of this occurrence. This study evaluated a neural network (NN), a supervised machine learning technique, to determine whether it could predict readmission after 3 lumbar fusion procedures. Methods The American College of Surgeons National Surgical Quality Improvement Program database was queried between 2009 and 2018. Patients who had undergone anterior, lateral, and/or posterior lumbar fusion were included in the study. The Python scikit Learn package was used to run the NN algorithm. A multivariate regression was performed to determine risk factors for readmission. Results There were 63,533 patients analyzed (12,915 anterior lumbar interbody fusion, 27,212 posterior lumbar interbody fusion, and 23,406 posterior spinal fusion cases). The NN algorithm was able to successfully predict 30-day readmission for 94.6% of anterior lumbar interbody fusion, 94.0% of posterior lumbar interbody fusion, and 92.6% of posterior spinal fusion cases with area under the curve values of 0.64–0.65. Multivariate regression indicated that age >65 years and American Society of Anesthesiologists class >II were linked to increased risk for readmission for all 3 procedures. Conclusions The accurate metrics presented indicate the capability for NN algorithms to predict readmission after lumbar arthrodesis. Moreover, the results of this study serve as a catalyst for further research into the utility of machine learning in spine surgery.

Introduction Spinal stenosis has a wide range of causes including disc herniation, facet hypertrophy, degenerative spondylosis, facet cyst, ossification of the ligamentum flavum (OLF) and ossification of the posterior longitudinal ligament (OPLL). We present three cases of diffuse spinal hyperostosis causing severe spinal stenosis and myelopathy, which demonstrate a unique association between obesity and a novel syndrome of hyperostosis. Case Presentation This report describes 3 morbidly obese patients with diffuse spinal hyperostosis causing critical thoracic stenosis. Their presenting complaints focus on lower extremity weakness and the CT/MRI imaging is striking for diffuse hyper-ossification at thoracic levels. Two patients were subsequently managed with spinal decompression, and one patient was managed non-operatively. Discussion Metabolic changes associated with obesity may result in diffuse hyperostosis with ligament ossification and spinal stenosis. Pre-operative imaging is essential to identify the degree of ossification and potential dural involvement as this may complicate management.

Study Design Retrospective cohort study using PearlDiver database. Objectives To evaluate the effect of prior thyroidectomy on complications of Anterior Cervical Discectomy and Fusion (ACDF) surgery. Methods PearlDiver was used to identify patients without prior dysphagia or dysphonia undergoing ACDF between the years 2010-2020Q1. Patients with and without prior thyroidectomy were matched by levels of fusion, alcohol use, and gastroesophageal reflux disease in a 1:5 ratio. Postoperative outcomes were assessed for each cohort with multivariable logistic regression, controlling for age, sex, and Elixhauser Comorbidity Index. Results Between 2010 and 2019, matched cohorts of 792 ACDF patients with prior thyroidectomy and 3960 ACDF only patients were included in the study. Of patients with previous thyroidectomy undergoing ACDF, 16.3% experienced dysphagia at 1-year compared with 10.6% for patients undergoing ACDF only (aOR=1.39, P=.004). Patients with previous thyroidectomy also had higher odds of dysphonia at 1-year following ACDF, as compared to patients with ACDF alone (2.7% vs 1.2%, aOR=1.74, P= .048). Patients undergoing ACDF with prior thyroidectomy did not have increased risk of revision at 1 year (aOR=1.10, P=.698), 2 years (aOR=1.16, P=.457), or 5 years (aOR=1.20, P=.255) following surgery. There were no differences in postoperative opioid utilization rates at 1 month (aOR=2.07, P=.138), 3 months (aOR=2.45, P=.095), 6 months (aOR=1.34, P=.520), and 12 months (aOR=1.69, P=.202). Prior thyroidectomy was not associated with reintubation following ACDF (P=.995). Conclusions Patients with prior thyroidectomy undergoing ACDF surgery experience increased odds of dysphagia and dysphonia at 1-year follow-up compared to those without prior thyroidectomy.

Hip-spine syndrome is a complex challenge for orthopedic surgeons. We present a 60-year-old female with a history of spinal fusion and total hip arthroplasty. The patient underwent extension of the previous fusion with sacropelvic fixation, and 5 months later she presented with left posterior prosthetic hip dislocation which required sedation and closed reduction.Even with no change in lumbar lordosis or pelvic tilt and adequate acetabular cup position, extension of the fusion construct may predispose patients to dislocation. This may be the result of an increased lever arm acting at the hip joint, thereby leading to instability.

Objective To evaluate the relationship between chiropractic spinal manipulation and medical malpractice using a legal database. Methods The legal database VerdictSearch was queried using the terms “chiropractor” OR “spinal manipulation” under the classification of “Medical Malpractice” between 1988 and 2018. Cases with chiropractors as defendants were identified. Relevant medicolegal characteristics were obtained, including legal outcome (plaintiff/defense verdict, settlement), payment amount, nature of plaintiff claim, and type and location of alleged injury. Results Forty-eight cases involving chiropractic management in the United States were reported. Of these, 93.8% (n = 45) featured allegations involving spinal manipulation. The defense (practitioner) was victorious in 70.8% (n = 34) of cases, with a plaintiff (patient) victory in 20.8% (n = 10) (mean payment $658,487 ± $697,045) and settlement in 8.3% (n = 4) (mean payment $596,667 ± $402,534). Overaggressive manipulation was the most frequent allegation (33.3%; 16 cases). A majority of cases alleged neurological injury of the spine as the reason for litigation (66.7%, 32 cases) with 87.5% (28/32) requiring surgery. C5-C6 disc herniation was the most frequently alleged injury (32.4%, 11/34, 83.3% requiring surgery) followed by C6-C7 herniation (26.5%, 9/34, 88.9% requiring surgery). Claims also alleged 7 cases of stroke (14.6%) and 2 rib fractures (4.2%) from manipulation therapy. Conclusions Litigation claims following chiropractic care predominately alleged neurological injury with consequent surgical management. Plaintiffs primarily alleged overaggressive treatment, though a majority of trials ended in defensive verdicts. Ongoing analysis of malpractice provides a unique lens through which to view this complicated topic.

Flexion-distraction, axial loading, and rotational forces can cause various degrees of osseoligamentous disruption of the cervical spine, leading to traumatic cervical facet fractures and dislocations.Low-energy forces lead to minimally displaced facet fractures that often can be treated with immobilization only. High-energy forces are more likely to cause unstable injuries with or without neurologic compromise, which may require surgical intervention.The initial treatment of cervical facet injuries requires patient evaluation and management through the Advanced Trauma Life Support (ATLS) protocols, while definitive management varies based on the biomechanical components of the injury, the neurologic status of the patient, and additional patient factors.Cervical facet injuries often require a multidisciplinary approach to optimize long-term functional outcomes and minimize serious complications.

Phantom limb syndrome is a debilitating complication after extremity amputation that poses significant challenges to recovery. This study aims to examine the relationship between phantom limb syndrome and mental and physical comorbidities, including a comparison between phantom limb pain and phantom limb syndrome without pain in below knee amputees.This is a retrospective cohort study of patients who underwent below knee amputation of the lower extremity in the PearlDiver database, as identified using CPT codes. Analysis was carried out to evaluate the absence or presence of phantom limb syndrome. Matched bivariate analysis accounting for age, sex, Charlson Comorbidity Index score, and region was used to assess whether the presence of pain in phantom limb syndrome patients was associated with increased comorbidity.In total, 44,028 patients with below knee amputation were examined: 95% (42,493 patients) did not develop phantom limb syndrome while 4.8% (1,535 patients) of patients did develop phantom limb syndrome. Phantom limb syndrome was significantly associated with increased odds of coexistent major depressive disorder (OR = 1.86, p0.0001), generalized anxiety disorder (OR = 2.14, p = 0.04), posttraumatic stress disorder (OR = 1.7, p0.0001), suicidal ideation (OR = 1.62, p0.0001), obesity (OR = 1.28, p = 0.0007), osteoarthritis (OR = 1.53, p0.0001), osteoporosis (OR = 1.64, p0.0001), and low back pain (OR = 2.31, p0.0001). Analysis of patient cohorts of phantom limb syndrome with pain and those without pain did not reveal a statistically significant relationship between the presence of pain and any dependent variable.This investigation of over 44,000 patients with below knee amputation revealed that patients with phantom limb syndrome exhibit significantly higher rate of psychiatric comorbidities compared to those without documented phantom limb pain. Suicidal ideation, major depressive disorder, generalized anxiety disorder, and post-traumatic stress disorder were especially common, and consequently a multi-disciplinary approach to management is essential.

Cervical laminoplasty (LP) and laminectomy with fusion (LF) are common operations used to treat cervical spondylotic myelopathy. Conflicting data exist regarding which operation provides superior patient outcomes while minimizing the risk of complications. This study evaluates the trends of LP compared with LF over the past decade in patients with cervical myelopathy and examines long-term revision rates and complications between the two procedures.Patients aged 18 years or older who underwent LP or LF for cervical myelopathy from 2010 to 2019 were identified in the PearlDiver Mariner Database. Patients were grouped independently (LP versus fusion) and assessed for association with common medical and surgical complications. The primary outcome was the incidence of LP versus LF for cervical myelopathy over time. Secondary outcomes were revision rates up to 5 years postoperatively and the development of complications attributable to either surgery.In total, 1,420 patients underwent LP and 10,440 patients underwent LF. Rates of LP (10.5% to 13.7%) and LF (86.3% to 89.5%) remained stable, although the number of procedures nearly doubled from 865 in 2010 to 1,525 in 2019. On matched analysis, LP exhibited lower rates of wound complications, surgical site infections, spinal cord injury, dysphagia, cervical kyphosis, limb paralysis, incision and drainage/exploration, implant removal, respiratory failure, renal failure, and sepsis. Revision rates for both procedures at were not different at any time point.From 2010 to 2019, rates of LP have not increased and represent less than 15% of posterior-based myelopathy operations. Up to 5 years of follow-up, there were no differences in revision rates for LP compared with LF; however, LP was associated with fewer postoperative complications than LF.Level III retrospective cohort study.

Ossification of the ligamentum flavum (OLF) is an uncommon but potentially serious spinal condition which can cause progressive compression of the spinal canal with associated devastating neurologic compromise. Although debate exists regarding the exact etiology of OLF, overexpression of genes and transcription factors centered around the Notch and Wnt signaling pathways because of increased mechanical stress seems to be related. There are many clinical and radiographic presentations of OLF; however, progressive myelopathy is the most commonly encountered. Radiographic analysis may reveal isolated OLF or OLF combined with ossification of other areas of the spine, such as disk, posterior longitudinal ligament, and dura. When surgery is necessary for OLF, several surgical strategies exist including open laminectomy with excision, endoscopic decompression, Bridge Crane resection, en block resection, and combined anterior and posterior approaches. Resection may be complicated by dural adhesion or dural ossification, and postoperative neurologic deficits are not uncommon.

Cauda equina syndrome (CES) is a potentially devastating spinal condition requiring prompt diagnosis and intervention. This study examines the relationship between timing of surgery and patient outcomes such as mortality and total complications, and longitudinal trends in timing of operative treatment over the years 2000-2014.This study considered patients in the Healthcare Cost and Utilization Project National Inpatient Sample Database between 2000 and 2014 who had both an International Classification of Disease, Ninth Edition, Clinical Modification code for CES (344.61) and an International Classification of Disease, Ninth Edition, Clinical Modification procedure code for either disc excision (8051) or spinal canal exploration and decompression (0309) in their inpatient record. Patients were separated into an early surgical intervention cohort versus a delayed intervention cohort, and associated outcomes were analyzed using linear regression. Trends in timing of surgery were examined for the years 2000-2014, and linear regression was used to assess degree of change over time.In total, 20,924 patients with CES met inclusion criteria. Following adjustment for demographic variables, the delayed-intervention group was associated with statistically significant increased inpatient mortality (odds ratio [OR] 9.60, P = 0.002), total complications (OR 1.41, P = 0.018), and non-routine discharge (OR 2.37, P0.0001). The proportion of patients receiving early intervention within 48 hours remained unchanged from 2000 to 2014 ranging from 80.2% (2000-2002) to 76.2% (2012-2014) (P = 0.190).This study represents the largest investigation to date examining CES and reveals the timing of surgical management for CES has not changed appreciably from 2000 to 2014 despite mounting evidence for early decompression. Patients receiving decompression within 0 or 1 day after admission are associated with improved inpatient outcomes, including lower complication and mortality rates.

Background Fragility hip fractures are a common orthopedic injury seen in Emergency Departments, with variable outcomes that can range from average to devastating. Currently, few reliable metrics to predict which patients will suffer post-operative complications exist. The aim of this study was to determine if the number and type of pre-operative medications can help predict post-operative complications. Methods A prospectively collected database of hip fracture patients was retrospectively reviewed. Patients with isolated greater trochanteric fractures, periprosthetic fractures, or re-fractures were excluded. Pre-operative baseline characteristics as well as number and type of post-operative complications were reviewed. Any complication within 6 months of surgery and complications that could be directly attributable to the surgical procedure within 2 years of surgery were examined. Major complications (return to the operating room, deep infection, pulmonary, cardiac, and hematologic) and minor medical complications were assessed. A multivariate regression model was performed to identify independent risk factors. Results Three-hundred ninety-one patients were included. A majority were aged 80–90 and female, and lived at home prior to presentation. Overall, 33.7% of patients suffered a complication within a 2-year follow-up period. Mortality rates were 5.4%, 10.0%, and 14.9% over 30 days, 1 year, and 2 years, respectively. After assessing this relationship while controlling for age, sex, injury type, pre-operative residence, ambulatory status, ASA score, and CCI score, the relationship remained significant for both an increased number of complications ( P = .048) and a higher likelihood of having a complication ( P = .008). Cardiovascular ( P = .003), pulmonary ( P = .001), gout ( P = .002), or diabetes ( P = .042) medications were associated with a higher likelihood for experiencing a complication. Conclusions Our study suggests that there is a strong and linear relationship between the number and type of pre-operative medications taken and risk of post-operative complications. This exists for up to 8 medications, at which point further increase does not contribute to an increased risk of complication. This relationship exists even after controlling for confounding variables and can be used by surgeons to better counsel patients and families regarding their specific risk for suffering perioperative complications.

Bacterial infection is a common etiology for pseudarthrosis after transforaminal lumbar interbody fusion, although it is often difficult to identify because of a delayed presentation and normal laboratory values. The primary goal of this study was to present a series of cases demonstrating patients with infection-related pseudarthrosis successfully managed with anterior revision.We retrospectively reviewed patients presenting to a single academic spine center who were found to have evidence of Cutibacterium acnes or coagulase-negative Staphylococcus infection on routine culturing of lumbar interbody fusion revisions from July 2019 to January 2021. All patients underwent salvage of a transforaminal lumbar interbody fusion pseudarthrosis through an anterior lumbar approach.A total of six patients managed for pseudarthrosis secondary to suspected infection were eligible for this study (mean age 64.8 years, range 54-70 years; mean body mass index, range 24.5-39.1). Persistent radiculopathy was the primary presenting symptom in all patients with a mean time to revision of 17 months. Coagulase-negative Staphylococcus was the primary pathogen, identified from intraoperative samples in 50% of the cases. All patients demonstrated a resolution of symptoms after placement of an anterior lumbar interbody cage, without intraoperative complications, and a subsequent antibiotic regimen.Indolent infection is an under-recognized cause of pseudarthrosis of the lumbar spine. Revision surgery through an anterior lumbar approach, which promotes ease of cage removal and optimized alignment and surface area available for revision fusion, is sufficient to manage pseudarthrosis due to infection.

Complete and incomplete spinal cord injuries affect between 250,000 and 500,000 people on an annual basis worldwide. In addition to sensory and motor dysfunction, spinal cord injury patients also suffer from associated conditions such as neurogenic bowel and bladder dysfunction. The degree of dysfunction varies on the level, degree, and type of spinal cord injury that occurs. In addition to the acute surgical treatment of these patients, spine surgeons should understand how to manage neurogenic bowel and bladder care on both a short- and long-term basis to minimize the risk for complications and optimize potential for rehabilitation.

Antibiotic bone cement (ABC) is an effective tool for the prophylaxis and treatment of osteomyelitis due to the controlled, sustained release of local antibiotics. ABC has been proven to be effective in the orthopedic fields of arthroplasty and extremity trauma, but the adoption of ABC in spine surgery is limited. The characteristics of ABC make it an optimal solution for treating vertebral osteomyelitis (VO), a serious complication following spine surgery, typically caused by bacterial and sometimes fungal and parasitic pathogens. VO can be devastating, as infection can result in pathogenic biofilms on instrumentation that is dangerous to remove. New techniques, such as kyphoplasty and novel vertebroplasty methods, could amplify the potential of ABC in spine surgery. However, caution should be exercised when using ABC as there is some evidence of toxicity to patients and surgeons, antibiotic allergies, bone cement structural impairment, and possible development of antibiotic resistance. The purpose of this article is to describe the basic science of antibiotic cement utilization and review its usage in spine surgery.

Surgical robots were invented in the 1980s, and since then, robotic-assisted surgery has become commonplace. In the field of spine surgery, robotic assistance is utilized mainly to place pedicle screws, and multiple studies have demonstrated that robots can increase the accuracy of screw placement and reduce radiation exposure to the patient and the surgeon. However, this may be at the cost of longer operative times, complications, and the risk of errors in mapping the patient's anatomy.

Proximal junctional kyphosis (PJK) is a common and devastating complication after spinal deformity surgery with a high need for revision surgery. PJK often leads to poor patient outcomes and large societal costs, which has led to the development of multiple prophylactic methods which have yet to eliminate PJK. A novel method for PJK prevention includes placing suture anchors, rather than pedicle screws, above the spinal construct to function as a tether. This biomechanical investigation examined the insertional torque and pullout strength of pedicle screws compared to suture anchors on 6 cadaveric vertebrae (12 pedicles). The mean insertional torque was 0.802 ± 0.477 N*m for pedicle screws and 0.368 ± 0.310 N*m for suture anchors (p = 0.047). The mean pullout strength was 973.16 ± 202.03 N for pedicle screws and 206.94 ± 181.78 N for suture anchors (p

Mortality following surgical resection of spinal tumors is a devastating outcome. Naïve Bayes machine learning algorithms may be leveraged in surgical planning to predict mortality. In this investigation, we use a Naïve Bayes classification algorithm to predict mortality following spinal tumor excision within 30 days of surgery.Patients who underwent laminectomies between 2006 and 2018 for excisions of intraspinal neoplasms were selected from the National Surgical Quality Initiative Program. Naïve Bayes classifier analysis was conducted in Python. The area under the receiver operating curve (AUC) was calculated to evaluate the classifier's ability to predict mortality within 30 days of surgery. Multivariable logistic regression analysis was performed in R to identify risk factors for 30-day postoperative mortality.In total, 2094 spine tumor surgery patients were included in the study. The 30-day mortality rate was 5.16%. The classifier yielded an AUC of 0.898, which exceeds the predictive capacity of the National Surgical Quality Initiative Program mortality probability calculator's AUC of 0.722 (P0.0001). The multivariable regression indicated that smoking history, chronic obstructive pulmonary disease, disseminated cancer, bleeding disorder history, dyspnea, and low albumin levels were strongly associated with 30-day mortality.The Naïve Bayes classifier may be used to predict 30-day mortality for patients undergoing spine tumor excisions, with an increasing degree of accuracy as the model better performs by learning continuously from the input patient data. Patient outcomes can be improved by identifying high-risk populations early using the algorithm and applying that data to inform preoperative decision making, as well as patient selection and education.

To evaluate the effect of a recent history of total hip arthroplasty (THA) on primary lumbar spine fusion (LSF) for concurrent hip and spine disease.A total of 98,242 patient records from the PearlDiver Database were evaluated and divided into 3 cohorts: 1) patients with a history of LSF alone, 2) patients with a history of LSF for newly diagnosed lumbar disease after having a remote THA2 years previously, and 3) patients with a history of LSF after having recent THA2 years before LSF who initially presented with concurrent hip and lumbar spine disease and underwent THA before LSF. Postoperative outcomes were assessed with multivariable logistic regression to determine the effect of THA on outcomes after LSF with respect to postoperative complications, LSF revision rates, and opioid use.Patients who had LSF after a recent THA had increased risk of deep venous thrombosis (adjusted odds ratio [aOR], 1.39; P = 0.0191), neurologic complications (aOR, 1.81; P = 0.0459), prolonged opioid use (aOR, 1.22; P = 0.0032), and revision LSF (12.8%; P = 0.0004 vs. 9.9%; OR, 1.41; P0.0001; hazard ratio, 1.69; P0.0001). Patients who underwent LSF after a remote history of THA had no significant difference in DVT (4.2% vs. 2.6%, aOR, 1.31; P = 0.2190), neurologic complications (1.0% vs. 0.5%, aOR, 2.02; P = 0.1220), revision surgery (9.6% vs. 9.9%, aOR, 1.06; P = 0.7197), or prolonged opioid use (36.5% vs. 24.4%, aOR, 1.17; P = 0.1120).Patients who undergo LSF with a history of THA may be at increased risk of postoperative complications, revision LSF, and prolonged opioid use if their THA was performed for concurrent hip-spine disease in the recent past (2 years).

Background Thoracolumbar corpectomies require adequate anterior column spinal reconstruction, often achieved through a single static or expandable cage. Patients with larger vertebrae, or those who require a larger footprint of reconstruction placed via a posterior approach are technically challenging. The aim of this report was to describe a novel approach for reconstruction using two smaller expandable cages following corpectomy, in the setting of tumor and trauma. Methods These technical reports illustrate a novel intraoperative technique with reconstruction via dual expandable cages implanted posteriorly from a bilateral costotransversectomy and transpedicular approaches. Due to the smaller size of each cage, implantation in the vertebral column was achieved with minimal retraction of the spinal cord. Results Two patients underwent urgent corpectomy in the thoracolumbar spine using this technique. Clinical improvement was evident post-surgery and adequate spine stabilization was confirmed radiographically without cage migration or subsidence, at up to one year of clinical follow up. No iatrogenic neurological deficits were reported in each case as well. Conclusion To the authors' knowledge, this is the first report of a corpectomy where this surgical technique was implemented in the thoracolumbar spine. This technique created a large footprint of reconstruction with less retraction on the spinal cord during surgery, reducing the potential for neurological complications. An alternative strategy is to place a larger footprint reconstruction through an anterior or lateral approach; however, these techniques also have potential morbidity which require consideration.

Workers' compensation is an employer-funded insurance program that provides financial and medical benefits for employees injured at work. Because many occupational injuries are musculoskeletal in nature, the orthopaedic surgeon plays an important role in the workers' compensation system. Along with establishing the correct diagnosis and implementing an appropriate treatment plan, the clinician must understand the fundamental components of the workers' compensation system to manage an injured employee. Ultimately, effective claim management requires collaboration among the employer, the employee, the legal representatives, the insurance company, and the orthopaedic surgeon.

Proximal junctional kyphosis (PJK) is a common complication following fusion for Adult Spinal Deformity. PJK and proximal junctional failure (PJF) may lead to pain, neurological injury, reoperation, and increased healthcare costs. Efforts to prevent PJK and PJF have aimed to preserve or reconstruct the posterior spinal tension band and/or modifying instrumentation to allow for more gradual transitions in stiffness at the cranial end of long spinal constructs. We describe placement of an interlaminar fixation construct at the upper instrumented vertebra which may decrease PJK/PJF severity, and is placed with little additional operative time and minimal posterior soft tissue trauma.

BACKGROUND CONTEXT Lumbar decompression is a viable treatment option for spinal stenosis with neurogenic claudication that has failed conservative treatment. However, given the relatively high rates of reoperation with decompression alone (up to 23%) and the increased surgical burden associated with fusion, alternative stabilization techniques such as dynamic interlaminar spacers have been utilized with the goal of providing stabilization while also preserving motion and native biomechanics. PURPOSE The purpose of this study is to evaluate whether interlaminar spacers can effectively augment lumbar decompression in the treatment of symptomatic spinal stenosis. STUDY DESIGN/SETTING Retrospective cohort study at a single institution. PATIENT SAMPLE Ninety-seven patients were included for analysis. Forty-three of these patients underwent lumbar decompression with placement of an interlaminar spacer, and 54 underwent lumbar decompression alone. OUTCOME MEASURES Radiographic parameters: anterior disc height, posterior disc height, segmental alignment, lumbar lordosis, lumbar range of motion, and foraminal height were measured before and after surgery. Outcome measures such as complication rates, and reoperation rates were also compared between the two cohorts. METHODS This is a retrospective cohort study at a single institution between January 2013 and November 2016. Ninety-seven patients were included for analysis. Forty-three of these patients underwent lumbar decompression with placement of an interlaminar spacer, and 54 underwent lumbar decompression alone. Radiographic parameters such as anterior disc height, posterior disc height, segmental alignment, lumbar lordosis, lumbar range of motion, and foraminal height were measured before and after surgery. Outcome measures, complication rates, and reoperation rates were also compared between the two cohorts. RESULTS Patients in the interlaminar spacer cohort had a significant increase in mean posterior disc height (4.5 to 5.1, p = 0.04) and decrease in mean anterior disc height (9.2 to 8.5 mm, p = 0.02). No significant anterior or posterior disc height change occurred in the laminectomy alone cohort. Both groups had a statistically significant decrease in segmental lumbar lordosis, although there was no observed difference in this degree of change between the two groups and no change in overall lumbar lordosis from L1-S1 in either cohort. Both cohorts demonstrated significant improvement in both Visual Analog Scores (VAS) and Oswestry Disability Index (ODI) postoperatively. The two cohorts had similar rates of postoperative complications, and the interlaminar spacer group had a slightly lower rate of reoperation (11.6% vs 20.4%, p = 0.28). CONCLUSIONS These results indicate that lumbar decompression supplemented with interlaminar spacers can lead to substantial improvement in both clinical and radiographic outcomes. We also found that the interlaminar spacer cohort had similar rates of complications and a lower reoperation rate, which deviates from previously published studies that demonstrate a substantially higher complication rate with interlaminar spacers. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Orthopaedic surgery has become increasingly specialized, and most trainees currently complete subspecialty fellowship training. The purposes of this investigation were to evaluate recent trends in U.S. orthopaedic fellowship matches and to provide relevant analyses for future orthopaedic fellowship applicants and fellowship program directors.This study analyzed data from orthopaedic fellowship match programs from 2010 to 2017. For each fellowship, the following variables were analyzed: numbers of positions offered, participating programs, applicant registrations, rank lists submitted by applicants (i.e., completed applications), applicants matched, and filled positions. Applicant-matching success rate and percentage of total fellowship positions filled for each subspecialty were calculated, and trends were evaluated for significance and difference between subspecialties utilizing ordinary least-square regressions, with p0.05 indicating significance.From 2010 to 2017, the number of fellowship positions that were offered increased in all subspecialties (p0.05) except for spine (p = 0.44) and trauma (p = 0.92). Participating fellowship programs increased in all subspecialties (p0.05) except spine (p = 0.38) and sports medicine; the latter experienced the only significant decrease (p0.05). The largest significant increases (p0.05) in both applicant registrations (33.5%) and rank lists submitted by applicants (45.3%) were in adult reconstruction. The subspecialty with the highest applicant-matching success rate during the study period of 2010 to 2017 was sports (mean, 93.5%). Spine and trauma had the lowest applicant-matching success rates in 2016 to 2017. The percentage of positions filled across all subspecialties increased from 2011 to 2017 (p0.05); hand had the highest mean (96.6% filled), and adult reconstruction had the largest significant increase from 82.0% in 2010 to 95.5% in 2017 (p0.05).This investigation provides data with regard to current trends in the orthopaedic fellowship match. Specifically, adult reconstruction fellowship training has recently gained popularity at a more rapid rate than the other subspecialty fellowship pathways, although hand surgery consistently maintains a very high rate of positions filled. Our results for orthopaedic subspecialty fellowship match trends may assist fellowship directors with program planning and career advising and may also assist current residents with fellowship application expectations and career planning.

Low back pain is one of the most common patient afflictions. The economic burden of low back pain is over $100 billion annually. Symptoms often resolve over time, but definitive treatment should be tailored to the underlying pathology responsible for the low back pain.

Retrospective cohort study.Analyze medical malpractice verdicts and settlements associated with incidental durotomy.Incidental durotomy is a common complication of spine surgery. Although most intraoperative dural tears are repaired without sequelae, persistent Cerebrospinal Fluid leak, infection, or neurological injury can yield adverse outcomes. The medicolegal implications of incidental durotomy are poorly understood.Three separate, large legal databases were queried for cases involving incidental durotomy. Case, plaintiff, procedure, and outcome characteristics were analyzed.In total, 48 dural tear-related medical malpractice cases were analyzed. Most cases (56.3%) resulted in a ruling in favor of the defendant physician. Most cases alleged neurological deficits (86.7%). A large majority of cases without neurological sequelae had an outcome in favor of the defendant (83.3%). For cases involving a payment, the average amount was $2,757,298 in 2016 adjusted dollars. Additional surgery was required in 56.3% of cases, a delay in diagnosis/treatment of durotomy was present in 43.8%, and alleged improper durotomy repair was present in 22.9%. A favorable outcome for the plaintiff was more likely in cases with versus without alleged delay in diagnosis/treatment (61.9% vs. 29.6%, P = 0.025) and improper durotomy repair technique (72.7% vs. 35.1%, P = 0.040). Repeat surgery was not associated with favorable outcome for the plaintiff (42.8% cases with reoperation vs. 38.1% without, P = 0.486).This analysis of durotomy-associated closed malpractice claims after spine surgery is the largest yet conducted. Durotomy cannot always be considered an entirely benign event, and these findings have several direct implications for clinicians: late-presenting or dehiscent durotomy may be associated with adverse outcomes and subsequent risk of litigation, timely reoperation in the event of durotomy-related complications may not increase surgeon liability, and spine surgeons should be prepared to defend their choice of durotomy repair technique, should dehiscence occur.3.

Unrecognized and inadequately repaired intraoperative durotomies may lead to cerebrospinal fluid leak, pseudomeningocele, and other complications. Few studies have investigated durotomy that is unrecognized intraoperatively and requires additional postoperative management (hereafter, late-presenting dural tear [LPDT]), although estimates of LPDT range from 0.6 to 8.3 per 1,000 spinal surgeries. These single-center studies are based on relatively small sample sizes for an event of this rarity, all with10 patients experiencing LPDT.This investigation is the largest yet conducted on LPDT, and sought to identify incidence, risk factors for, and complications associated with LPDT.This observational cohort study employed the American College of Surgeons National Surgical Quality Improvement Program dataset (years 2012-2015).Patients who underwent spine surgery were identified based on presence of primary listed Current Procedural Terminology (CPT) codes corresponding to spinal fusion or isolated posterior decompression without fusion.The primary variable in this study was occurrence of LPDT, identified as reoperation or readmission with durotomy-specific CPT or International Classification of Diseases, Ninth Revision, Clinical Modification codes but without durotomy codes present for the index procedure.Descriptive statistics were generated. Bivariate and multivariate analyses were conducted using chi-square tests and multiple logistic regression, respectively, generating both risk factors for LPDT and independent association of LPDT with postoperative complications. Statistical significance was defined as p.05.In total, 86,212 patients were analyzed. The overall rate of reoperation or readmission without reoperation for LPDT was 2.0 per 1,000 patients (n=174). Of LPDT patients, 97.7% required one or more unplanned reoperations (n=170), and 5.7% of patients (n=10) required two reoperations. On multivariate analysis, lumbar procedures (odds ratio [OR] 2.79, p.0001, vs. cervical), procedures involving both cervical and lumbar levels (OR 3.78, p=.0338, vs. cervical only), procedures with decompression only (OR 1.72, p=.0017, vs. fusion and decompression), and operative duration ≥250 minutes (OR 1.70, p=.0058, vs.250 minutes) were associated with increased likelihood of LPDT. Late-presenting dural tear was significantly associated with surgical site infection (SSI) (OR 2.54, p.0001), wound disruption (OR 2.24, p.0001), sepsis (OR 2.19, p.0001), thromboembolism (OR 1.71, p.0001), acute kidney injury (OR 1.59, p=.0281), pneumonia (OR 1.14, p=.0269), and urinary tract infection (UTI) (OR 1.08, p=.0057).Late-presenting dural tears occurred in 2.0 per 1,000 patients who underwent spine surgery. Patients who underwent lumbar procedures, decompression procedures, and procedures with operative duration ≥250 minutes were at increased risk for LPDT. Further, LPDT was independently associated with increased likelihood of SSI, sepsis, pneumonia, UTI, wound dehiscence, thromboembolism, and acute kidney injury. As LPDT is associated with markedly increased morbidity and potential liability risk, spine surgeons should be aware of best-practice management for LPDT and consider it a rare, but possible etiology for developing postoperative complications.

Occupational spine injuries place a substantial burden on employees, employers, and the workers' compensation system. Both temporary and permanent spinal conditions contribute substantially to disability and lost wages. Numerous investigations have revealed that workers' compensation status is a negative risk factor for outcomes after spine injuries and spine surgery. However, positive patient outcomes and return to work are possible in spine-related workers' compensation cases with proper patient selection, appropriate surgical indications, and realistic postoperative expectations. Quality improvement measures aimed at optimizing outcomes and minimizing permanent disability are crucial to mitigating the burden of disability claims.

BACKGROUND CONTEXT Online physician rating websites are increasingly utilized by patients to evaluate their doctors. PURPOSE The purpose of this investigation was to evaluate factors associated with better spine surgeon ratings. STUDY DESIGN/SETTING Statistical analysis of publicly available data. PATIENT SAMPLE A total of 250 orthopedic spine surgeons were randomly selected from the North American Spine Society directory utilizing a random number generator. OUTCOME MEASURES Surgeon profiles on three physician rating websites, www.HealthGrades.com , www.Vitals.com , and www.RateMDs.com , were analyzed to gather qualitative and quantitative data on patients' perceptions of the surgeons. METHODS Independent variables from the websites were analyzed in relation to overall physician or patient satisfaction rating using independent-samples t-tests and linear regression analysis. Comments were coded by subject into three categories: professional competence, bedside manner, and practice characteristics. RESULTS A total of 250 surgeons were evaluated, and 92% (n=230) of these doctors had at least one rating among the three websites. The surgeons with a higher average rating had significantly better trust (p CONCLUSIONS This investigation assessed spine surgeon online patient ratings and categorized factors which patients associate with quality care. Trustworthiness was the most significant predictor of positive ratings, while ease of scheduling, quality of staff, helpfulness, and punctuality were also associated with higher patient ratings. Understanding what patients value may help optimize care of spine surgery patients.

BACKGROUND CONTEXT Cauda equina syndrome (CES) is a devastating spinal condition without a clear consensus on evidence-based treatment guidelines and reported patient outcomes. Due to the relative infrequency of this condition at individual institutions, the majority of the studies that investigate CES are underpowered with results that are difficult to apply to the general population. PURPOSE The purpose of this investigation was to use a large, nationwide patient sample of CES patients to identify demographic and procedural trends and recognize factors that influence outcomes. STUDY DESIGN/SETTING This investigation was a retrospective cohort study that identified patients with CES registered in the Nationwide Inpatient Sample (NIS) database from 2000 to 2014. PATIENT SAMPLE Patients were identified using the International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) code for cauda equina syndrome (344.61) and the ICD-9-CM procedure code for either disc excision (8051) or spinal canal exploration and decompression (0309). Demographic analysis included patient age, sex, median income per patient's zip code, and presenting institution (urban teaching vs urban non-teaching vs rural). ICD-9-CM codes for lumbar disc herniation (722.10, 722.73), spinal stenosis (724.02), tumor (198.5), postoperative hematoma (998.12), and trauma (806.4) were utilized to identify the most frequent etiologies of CES. OUTCOME MEASURES Outcome measures were retained for each observation, including inpatient mortality, total complications, postoperative length of stay, total charges, discharge disposition, average total charges and urinary catheterization rates. METHODS The impact of surgical timing on outcomes was investigated by separating patients into an early surgical intervention cohort (surgery on hospital day 0 or 1) versus a delayed intervention cohort (surgery on hospital day 2 or later). Patient outcomes and trends in the timing of surgical decompression were analyzed using linear regression. RESULTS A total of 20,924 cauda equina syndrome patients met inclusion criteria. Following adjustment for age, sex, race and median area code income, the delayed surgical intervention group was associated with significant differences including increased inpatient mortality (OR 9.60, p=.002), total complications (OR 1.41, p=.018) and non-routine discharge (OR 2.37, p CONCLUSIONS This study represents the largest investigation to date examining trends and outcomes in patients with CES. The results reveal that the timing of surgical management in CES patients has not changed appreciably from 2000-2014 despite mounting evidence of the benefit of early decompression. CES patients that undergo surgical decompression on hospital day 0 or 1 are observed to have improved inpatient outcomes, including lower complication and mortality rates. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

The objective of this study is to compare the performances of catalytic ozonation processes of two activated carbons prepared from olive stone (ACOS) and apricot stone (ACAS) with commercial ones (granular activated carbon-GAC and powder activated carbon-PAC) in degradation of reactive azo dye (Reactive Red 195). The optimum conditions (solution pH and amount of catalyst) were investigated by using absorbencies at 532, 220 and 280 nm wavelengths. Pore properties of the activated carbon (AC) such as BET surface area, pore volume, pore size distribution, and pore diameter were characterized by N-2 adsorption. The highest BET surface area carbon (1,275 m(2)/g) was obtained from ACOS with a particle size of 2.29 nm. After 2 min of catalytic ozonation, decolorization performances of ACOS and ACAS (90.4 and 91.3%, respectively) were better than that of GAC and PAC (84.6 and 81.2%, respectively). Experimental results showed that production of porous ACs with high surface area from olive and apricot stones is feasible in Turkey.

A 72-year-old man presented to his primary care physician with 1 week of difficulty ambulating and right thigh pain and numbness. Physical exam revealed weakness in his right hip flexor and quadriceps, along with pain and numbness in an L3 distribution. The patient had …