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OBJECTIVE Revision surgery is often necessary for adult spinal deformity (ASD) patients. Satisfaction with management is an important component of health-related quality of life. The authors hypothesized that patients who underwent multiple revision surgeries following ASD correction would exhibit lower self-reported satisfaction scores. METHODS This was a retrospective cohort study of 668 patients who underwent ASD surgery and were eligible for a minimum 2-year follow-up. Visits were stratified by occurrence prior to the index surgery (period 0), after the index surgery only (period 1), after the first revision only (period 2), and after the second revision only (period 3). Patients were further stratified by prior spine surgery before their index surgery. Scoliosis Research Society–22 (SRS-22r) health-related quality-of-life satisfaction subscore and total satisfaction scores were evaluated at all periods using multiple linear regression and adjustment for age, sex, and Charlson Comorbidity Index. RESULTS In total, 46.6% of the study patients had undergone prior spine surgery before their index surgery. The overall revision rate was 21.3%. Among patients with no spine surgery prior to the index surgery, SRS-22r satisfaction scores increased from period 0 to 1 (from 2.8 to 4.3, p < 0.0001), decreased after one revision from period 1 to 2 (4.3 to 3.9, p = 0.0004), and decreased further after a second revision from period 2 to 3 (3.9 to 3.3, p = 0.0437). Among patients with spine surgery prior to the index procedure, SRS-22r satisfaction increased from period 0 to 1 (2.8 to 4.2, p < 0.0001) and decreased from period 1 to 2 (4.2 to 3.8, p = 0.0011). No differences in follow-up time from last surgery were observed (all p > 0.3). Among patients with multiple revisions, 40% experienced rod fracture, 40% proximal junctional kyphosis, and 33% pseudarthrosis. CONCLUSIONS Among patients undergoing ASD surgery, revision surgery is associated with decreased satisfaction, and multiple revisions are associated with additive detriment to satisfaction among patients initially undergoing primary surgery. These findings have direct implications for preoperative patient counseling and establishment of postoperative expectations.

Retrospective cohort study.Determine whether screws per level and rod material/diameter are associated with incidence of proximal junctional kyphosis (PJF).PJF is a common and particularly adverse complication of adult spinal deformity (ASD) surgery. There is evidence that the rigidity of posterior spinal constructs may impact risk of PJF.Patients with ASD and 2-year minimum follow-up were included. Only patients undergoing primary fusion of more than or equal to five levels with lower instrumented vertebrae (LIV) at the sacro-pelvis were included. Screws per level fused was analyzed with a cutoff of 1.8 (determined by receiver operating characteristic curve (ROC) analysis). Multivariable logistic regression was utilized, controlling for age, body mass index (BMI), 6-week postoperative change from baseline in lumbar lordosis, number of posterior levels fused, sex, Charlson comorbidity index, approach, osteotomy, upper instrumented vertebra (UIV), osteoporosis, preoperative TPA, and pedicle screw at the UIV (as opposed to hook, wire, etc.).In total, 504 patients were included. PJF occurred in 12.7%. The mean screws per level was 1.7, and 56.8% of patients had less than 1.8 screws per level. No differences were observed between low versus high screw density groups for T1-pelvic angle or magnitude of lordosis correction (both P 0.15). PJF occurred in 17.0% versus 9.4% of patients with more than or equal to 1.8 versus less than 1.8 screws per level, respectively (P 0.05). In multivariable analysis, patients with less than 1.8 screws per level exhibited lower odds of PJF (odds ratio (OR) 0.48, P 0.05), and a continuous variable for screw density was significantly associated with PJF (OR 3.87 per 0.5 screws per level, P 0.05). Rod material and diameter were not significantly associated with PJF (both P 0.1).Among ASD patients undergoing long-segment primary fusion to the pelvis, the risk of PJF was lower among patients with less than 1.8 screws per level. This finding may be related to construct rigidity. Residual confounding by other patient and surgeon-specific characteristics may exist. Further biomechanical and clinical studies exploring this relationship are warranted.Level of Evidence: 3.

BACKGROUND Interhospital competition has been shown to affect surgical outcomes and expenditures. However, interhospital competition's impact on neurosurgery is poorly characterized. OBJECTIVE To assess how interhospital competition is associated with treatment strategy and outcomes for unruptured intracranial aneurysms (UIAs). METHODS We identified all elective UIA admissions in the National Inpatient Sample from 2002 to 2011. Competitive intensity of each hospital market was quantified using the validated Herfindahl-Hirschman Index (HHI), with lower values denoting higher competition. We then obtained nationwide HHI values for 2012 to 2016 from the Health Care Cost Project. Outcomes included treatment modality (clipping, coiling, or nonoperative management), inpatient mortality, disposition, complications, length of stay (LOS), and costs. Multivariate regression assessed the association between HHI and outcomes, controlling for patient demographics, severity metrics, hospital characteristics, and treatment. RESULTS We studied 157 979 elective UIA admissions at 1435 hospitals from 2002 to 2011, with an increase in coiling admissions (13.4% to 33.7%) and decrease in clipping admissions (30.9% to 17.6%). Mean hospital HHI was 0.11 (range = 0.001-0.97). Competition decreased for 61.8% of hospitals from 2002 to 2011 and 68.1% of metropolitan localities from 2012 to 2016. Admissions in more competitive hospital markets exhibited increased odds of undergoing surgery (odds ratio [OR] = 1.37, P

Study design Retrospective case-control study. Objective The aim of this study was to determine the influence of obesity on risk factors for adverse outcome after lumbar spine fusion (LSF). Summary of background data Obesity is risk factor for complications after LSF and poses unique challenges regarding optimization of care. Nonetheless, this patient population is not well-studied. Methods Adult patients undergoing LSF were identified the State Inpatient Database. Patients were identified as obese or nonobese using ICD-9 codes. Outcome variables were 90-day readmission, major medical complication, infection, and revision rates. Data were queried for demographics, comorbidities, surgery characteristics, and outcome variables. Logistic multivariate regression was utilized, serially testing interactions between obesity and other independent variables in separate models for each outcome. The Benjamini-Hochberg procedure was used to adjust statistical significance for multiple comparisons. Results A total of 262,153 patients were included: 31,062 obese and 231, 091 nonobese. For major complications, obese patients had lower odds ratios (ORs) versus nonobese patients for cerebrovascular accident, diabetes with chronic complications, age ≥65, congestive heart failure, history of myocardial infarction, renal disease, chronic pulmonary disease, Medicare/Medicaid payor, more than two levels fused, transforaminal/posterior lumbar interbody fusion, and female sex, and higher OR for non-White race. For readmission, obese patients had lower OR for age ≥65, history of MI, renal disease, and mental health disease, and higher OR for female sex. For revision, obese patients had higher OR for female sex and TLIF/PLIF. For infection, obese patients had lower OR for diabetes with and without chronic complications, and higher OR for female sex. Conclusion Many medical comorbidities have less impact in obese patients than nonobese patients in predicting adverse outcomes despite increased rates of adverse outcomes in obese patients. These findings reflect the impact of obesity as an independent risk factor and have important implications for preoperative optimization.Level of Evidence: 3.

Introduction The COVID-19 pandemic resulted in a transition to a virtual format for all medical residency and fellowship application processes. Previous studies have discussed the successful implementation of virtual interviews, but a deep analysis of how the application process has changed for orthopedic surgery fellowship programs during the pandemic is lacking. The purpose of this study was to assess how COVID-19 impacted the orthopedic spine fellowship application and selection process. Methods A web-based survey was administered to the program directors of all 75 U.S. orthopedic surgery spine fellowship programs, which often can accept both orthopedic surgery and neurosurgery trained graduates. Questions focused on the changes from the 2019-2020 application cycle to the 2020-2021 cycle. We collected data on connecting with potential applicants, the general application process, and interviews offered by programs. Univariate analyses were used to compare data from the 2020-2021 cycle with the prior 2019-2020 cycle. Results Twenty-five of the 75 contacted program directors responded to our survey (33% response rate). The percentage of programs that offered virtual open houses/meet-and-greets increased from 20% in 2019-2020 to 52% in 2020-2021 (p=0.018). Social media use was unchanged (0.0% vs. 4.0%, p0.05). Compared to the prior year, the number of interviews offered by programs increased by 1.5 (32.7 vs. 21.9 interviews, p=0.024). There were no significant differences in the numbers of applications received by programs, interview dates available, or separate interviews each candidate completed during an interview day (p0.05 for all). The in-person interview was the most important factor in 2019-2020 for selecting applicants, whereas the virtual interview, letters of recommendation (LOR), and research were equally ranked as the most important factors in 2020-2021. Regarding interviews, 50% of respondents would "likely" consider virtual interviews as an option in addition to in-person interviews in the future, but most (55%) answered that it was "unlikely" that virtual interviews would entirely replace in-person interviews. Conclusion Spine fellowship programs were more likely to use virtual social events to recruit potential applicants, send out more interview invitations, and equally consider LOR and research with interview performance during an entirely virtual application cycle. Half of the program directors would consider offering virtual interviews as an option for future application cycles, which may help reduce costs associated with the process.

Objective Patients with ASD show complex and highly variable disease. The decision to manage patients operatively is largely subjective and varies based on surgeon training and experience. We sought to develop models capable of accurately discriminating between patients receiving operative versus nonoperative treatment based only on baseline radiographic and clinical data at enrollment. Methods This study was a retrospective analysis of a multicenter consecutive cohort of patients with ASD. A total of 1503 patients were included, divided in a 70:30 split for training and testing. Patients receiving operative treatment were defined as those undergoing surgery up to 1 year after their baseline visit. Potential predictors included available demographics, past medical history, patient-reported outcome measures, and premeasured radiographic parameters from anteroposterior and lateral films. In total, 321 potential predictors were included. Random forest, elastic net regression, logistic regression, and support vector machines (SVMs) with radial and linear kernels were trained. Results Of patients in the training and testing sets, 69.0% (n = 727) and 69.1% (n = 311), respectively, received operative management. On evaluation with the testing dataset, performance for SVM linear (area under the curve =0.910), elastic net (0.913), and SVM radial (0.914) models was excellent, and the logistic regression (0.896) and random forest (0.830) models performed very well for predicting operative management of patients with ASD. The SVM linear model showed 86% accuracy. Conclusions This study developed models showing excellent discrimination (area under the curve >0.9) between patients receiving operative versus nonoperative management, based solely on baseline study enrollment values. Future investigations may evaluate the implementation of such models for decision support in the clinical setting.

Sexual function is an important factor contributing to quality of life. Adult spinal deformity (ASD) patients may have sexual limitations due to lumbar spinal stiffness that may be affected by long-segment fusion.This study utilized a multicenter, prospectively defined, consecutive cohort of ASD patients. The primary outcome in this study was the Lumbar Stiffness Disability Index (LSDI) question 10: "Choose the statement that best describes the effect of low back stiffness on your ability to engage in sexual intercourse".In total, 368 patients were included in this study, including 76 men and 292 women, of which 80.7% (n = 293) underwent 9 or more level fusion and 74.4% (n = 270) had pelvic fixation. Baseline LSDI sexual function scores averaged 1.7 (SD 1.3), which improved to 1.3 (SD 1.2) at 2-year follow-up (P = 0.0008). After adjusting for confounding factors, worse LSDI sexual function score was strongly associated with worse Oswestry Disability Index, Scoliosis Research Society-22r total, and SF-36 Physical Component Summary and Mental Component Summary scores at both baseline and 2-year follow-up (p0.05 for all comparisons). Predictors of poorer baseline sexual function included older age, increased SVA, and increased back pain (p0.05 for all comparisons). Predictors of improvement in sexual function at 2-year follow-up included sagittal vertical axis improvement (P = 0.0032) and decreased postoperative back pain (P0.0001).This study found that sexual dysfunction scores due to lumbar stiffness significantly improved after surgery for ASD. Additionally, lumbar stiffness-related sexual dysfunction is strongly related to overall outcome measured by Oswestry Disability Index and Scoliosis Research Society-22r total score, highlighting the importance of sexual health on overall outcome in ASD patients.

Objective The purpose of this study was to compare differences in the outcomes of patients who undergo anterior cervical diskectomy and fusion (ACDF) with and without a history of shoulder arthroscopy. Methods The PearlDiver Patient Records Database ( www.peardiverinc.com ) from 2007 to 2017 was used to query patients by Current Procedural Terminology, isolating those who underwent ACDF with and without prior shoulder arthroscopy. Postoperative complications within 30 days of the index procedure, opioid use, and revision procedures were assessed for each cohort using ICD-9/10 and Current Procedural Terminology coding. Results A total of 39,969 ACDF patients were queried, of which 38,859 (97.2%) underwent ACDF alone and 1110 (2.8%) underwent ACDF with prior shoulder arthroscopy. ACDF revision rates were significantly greater in patients with prior shoulder arthroscopy compared with ACDF alone (5.8% vs. 3.6%, aOR = 1.64, P = 0.0002). Patients with prior shoulder arthroscopy were also significantly more likely to fill opioid prescriptions at 3 months (aOR 1.19, P = 0.02), 6 months (aOR 1.22, P = 0.01), and 12 months (aOR 1.18, P = 0.04). Conclusions Patients who undergo ACDF with a prior shoulder arthroscopy have significantly greater revision rates, respiratory complications, and prolonged opioid use compared with patients without prior shoulder arthroscopy. With efforts to limit narcotic use and the importance of maximizing patient satisfaction, this analysis improves on the surgeon's ability to set expectations and postoperative plans for patients undergoing ACDF who have a history of shoulder arthroscopy.

Periprosthetic fracture (PPF) after total hip arthroplasty (THA) is associated with adverse outcomes. Many studies have sought to determine risk factors for PPF, though controversy exists regarding several variables. This study sought to determine risk factors for early PPF using the National Surgical Quality Improvement Program (NSQIP) dataset. Patients with a primary current procedural terminology for THA were identified. The primary outcome was reoperation/readmission for PPF within 30 days. Multivariable logistic regression was utilized to adjust for confounding factors. A total of 159,234 patients were included in the study, of whom 195 patients (0.12%) had a PPF within 30 days, with a mean day of reoperation/readmission of 14.6 (standard deviation 7.7). A total of 68 patients (34.9% of those fractured) underwent one or more reoperations. In multivariable analysis, risk factors for PPF were higher body mass index (BMI; odds ratio [OR] 1.03 per mg/kg2, 95% confidence interval [CI] 1.0–1.05) and higher preoperative leukocyte count (OR 1.04 per 103/mL, 95% CI 1.01–1.06). Among females, age (OR 1.05 per year, 95% CI 1.04–1.07) was significantly associated with PPF, but a similar difference was not observed among males (OR 1.01, 95% CI 0.98–1.04). Controlling for patient age, there was no significant difference in risk of PPF for females versus males (p = 0.2213). PPF was associated with the development of additional complications (OR 4.10, 95% CI 2.68–6.27). This study identified risk factors for PPF after primary THA. These results have implications for preoperative planning and postoperative precautions among patients with particularly elevated risk of PPF.

Prosthetic dislocation in total hip arthroplasty (THA) is the most common cause for readmission in the 90 days following surgery. This investigation sought to quantify risk factors for readmission for early prosthetic dislocation within 30 days after primary THA. This study used the National Surgical Quality Improvement Program (NSQIP) database for the years 2012 to 2017. The primary outcome was reoperation or readmission for prosthetic dislocation within 30 days after primary total hip replacement. Secondary outcomes included native NSQIP medical complications. A total of 159,234 patients were included. Of these, 0.25% (n = 399) experienced reoperation or readmission for prosthetic dislocation within 30 days postoperatively. A total of 217 dislocated hips (54.4%) returned to the operating room only once, and 27 hips (6.8%) returned to the operating room twice. The mean day of first reoperation/readmission for dislocation was 13.5 (standard deviation [SD]: 9.0). In multivariable logistic regression, the following factors were significantly associated with early reoperation/readmission for prosthetic dislocation: patient age 80+ years (odds ratio [OR]: 1.51 vs. 50–59), high creatinine (OR: 1.75 vs. normal range), smoking (OR: 1.53), history of severe chronic obstructive pulmonary disease (COPD) (OR: 1.73), general anesthesia (OR: 1.41 vs. spinal), American Society of Anesthesiologists (ASA) class 3–5 (OR: 1.66 vs. 1 or 2), fracture (OR: 2.17), chronic steroid use (OR: 1.54), and operative duration ≥ 2 hours (all p

Out-of-pocket (OOP) costs for medical and surgical care can result in substantial financial burden for patients and families. Relatively little is known regarding OOP costs for commercially insured patients receiving orthopaedic surgery. The aim of this study is to analyze the trends in OOP costs for common, elective orthopaedic surgeries performed in the hospital inpatient setting.This study used an employer-sponsored insurance claims database to analyze billing data of commercially insured patients who underwent elective orthopaedic surgery between 2014 and 2019. Patients who received single-level anterior cervical diskectomy and fusion (ACDF), single-level posterior lumbar fusion (PLF), total knee arthroplasty (TKA), and total hip arthroplasty (THA) were identified. OOP costs associated with the surgical episode were calculated as the sum of deductible payments, copayments, and coinsurance. Monetary data were adjusted to 2019 dollars. General linear regression, Wilcoxon-Mann-Whitney, and Kruskal-Wallis tests were used for analysis, as appropriate.In total, 10,225 ACDF, 28,841 PLF, 70,815 THA, and 108,940 TKA patients were analyzed. Most patients in our study sample had preferred provider organization insurance plans (ACDF 70.3%, PLF 66.9%, THA 66.2%, and TKA 67.0%). The mean OOP costs for patients, by procedure, were as follows: ACDF $3,180 (SD = 2,495), PLF $3,166 (SD = 2,529), THA $2,884 (SD = 2,100), and TKA $2,733 (SD = 1,994). Total OOP costs increased significantly from 2014 to 2019 for all procedures (P0.0001). Among the insurance plans examined, patients with high-deductible health plans had the highest episodic OOP costs. The ratio of patient contribution (OOP costs) to total insurer contribution (payments from insurers to providers) was 0.07 for ACDF, 0.04 for PLF, 0.07 for THA, and 0.07 for TKA.Among commercially insured patients who underwent elective spinal fusion and major lower extremity joint arthroplasty surgery, OOP costs increased from 2014 to 2019. The OOP costs for elective orthopaedic surgery represent a substantial and increasing financial burden for patients.

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 Meningocele manque (MM) is characterized by tethering of the spinal cord, nerve roots, or filum terminale by fibrous attachments formed by atrophic or incomplete meningoceles. Patients with MM can present with symptoms of tethered cord syndrome (TCS). Case Description We present the case of an MM discovered incidentally during microsurgical resection of filum terminale for occult TCS. The MM was not visible on the preoperative magnetic resonance imaging (MRI) studies. After L2-L3 laminotomy, an extradural mass was appreciated adherent to the spinal dura, which was found to be an MM. The nerve roots of the cauda equina were found to protrude through the dura, consistent with tethered cauda equina. After microsurgical resection of the filum terminale, the tethered cauda nerve roots were stimulated, and redundant electromyographic signals were detected at both the left- and the right-sided muscles of the lower extremities. Microsurgical repair of the MM was performed, assuming that the patient's symptoms of TCS would also be explained by the MM and that her symptoms would likely have been incompletely addressed by filum terminale release alone. A review of the preoperative 3-dimensional constructive interference in steady state MRI sequence revealed pathological features at the L2-L3 level suspicious for our intraoperative findings of an MM. Conclusions Surgeons planning filum terminale release for occult TCS should always be aware of the possibility of associated pathological features of tethering that might be overlooked. In retrospect, the detection of MM was enabled by the high-resolution 3-dimensional constructive interference in steady state MRI sequence. This finding advocates for the use of high-resolution MRI for patients undergoing evaluation for occult TCS to detect pathological features that might otherwise be undetected.

The Lumbar Stiffness Disability Index (LSDI) assesses impact of lumbar stiffness on activities of daily living. We hypothesized that patients60 years old would perceive greater lumbar stiffness-related functional limitation following fusion for adult spinal deformity.Patients completed the LSDI and Scoliosis Research Society 22 Questionnaire, Revised (SRS-22r) preoperatively and at 2 years postoperatively. The primary independent variable was patient age60 versus ≥60. Multivariable regression analyses were used.Analysis included 267 patients. Patients60 years old (51.3%) and ≥60 years old (48.7%) were evenly represented. In bivariable analysis, patients age60 exhibited lower LSDI at baseline versus patients age ≥60 (25.7 vs. 35.5, β -9.8, P0.0001), but a directionally smaller difference at 2 years (26.4 vs. 32.3, β -5.8, P = 0.0147). LSDI was associated with lower SRS-22r total score among both age groups at baseline and 2 years (all P0.0001); the association was stronger among patients age60 versus ≥60 at 2 years. LSDI was associated with SRS-22r satisfaction scores at 2 years among patients age60 (P0.0001), but not patients age ≥60 (P = 0.2250). The difference in SRS-22r satisfaction per unit LSDI between patients60 years old and ≥60 years old was significant (P = 0.0021).Among patients with adult spinal deformity managed operatively, higher LSDI was associated with inferior SRS-22r total score and satisfaction at 2 years postoperatively. The association between increased LSDI and worse patient-reported outcome measures was greater among patients age60 versus ≥60. Preoperative counseling is needed for patients age60 undergoing adult spinal deformity surgery regarding effects that lumbar stiffness may have on postoperative function and satisfaction.

Retrospective cohort study.We hypothesized that adult spinal deformity (ASD) surgery would be associated with improved work- and school-related productivity, as well as decreased rates of absenteeism.ASD patients experience markedly decreased health-related quality of life along many dimensions.Only patients eligible for 2-year follow-up were included, and those with a history of previous spinal fusion were excluded. The primary outcome measures in this study were Scoliosis Research Society-22r score (SRS-22r) questions 9 and 17. A repeated measures mixed linear regression was used to analyze responses over time among patients managed operatively (OP) versus nonoperatively (NON-OP).In total, 1188 patients were analyzed. 66.6% were managed operatively. At baseline, the mean percentage of activity at work/school was 56.4% (standard deviation [SD] 35.4%), and the mean days off from work/school over the past 90 days was 1.6 (SD 1.8). Patients undergoing ASD surgery exhibited an 18.1% absolute increase in work/school productivity at 2-year follow-up versus baseline (P 0.0001), while no significant change was observed for the nonoperative cohort (P 0.5). Similarly, the OP cohort experienced 1.1 fewer absent days over the past 90 days at 2 years versus baseline (P 0.0001), while the NON-OP cohort showed no such difference (P 0.3). These differences were largely preserved after stratifying by baseline employment status, age group, sagittal vertical axis (SVA), pelvic incidence minus lumbar lordosis (PI-LL), and deformity curve type.ASD patients managed operatively exhibited an average increase in work/school productivity of 18.1% and decreased absenteeism of 1.1 per 90 days at 2-year follow-up, while patients managed nonoperatively did not exhibit change from baseline. Given the age distribution of patients in this study, these findings should be interpreted as pertaining primarily to obligations at work or within the home. Further study of the direct and indirect economic benefits of ASD surgery to patients is warranted.Level of Evidence: 3.

A retrospective study.This study sought to characterize the incidence and timing of postoperative emergency department (ED) visits after common outpatient spinal surgeries performed at ambulatory surgery centers (ASCs) and at hospital outpatient departments (HOPDs).Outpatient spine surgery has markedly grown in popularity over the past decade. The incidence of ED visits after outpatient spine surgery is not well established.This study was a retrospective analysis of a large commercial claims insurance database of patients 65 years old and below. Patients who underwent single-level anterior cervical discectomy and fusion, laminectomy, and microdiscectomy were identified. Incidence, timing, and diagnoses associated with ED visits within the postoperative global period (90 d) after surgery were assessed.In total, 202,202 patients received outpatient spine surgery (19.1% in ASC vs. 80.9% in HOPD). Collectively, there were 22,198 ED visits during the 90-day postoperative period. Approximately 9.0% of patients had at least 1 ED visit, and the incidence varied by procedure: anterior cervical discectomy and fusion 9.9%, laminectomy 9.5%, and microdiscectomy 8.5% ( P0.0001). After adjusting for age, sex, and comorbidity index, the odds of at least 1 ED visit were higher among patients who received surgery at HOPD versus ASC for all 3 procedures. The majority (56.1%) ED visits occurred during the first month postoperatively; 30.8% (n=6841) occurred within the first week postoperatively, and 10.7% (n=2370) occurred on the same day as the surgery. Postoperative pain was the most common reason for ED visits.Among commercially insured patients who received outpatient spine surgery, the incidence of ED visits during the 90-day postoperative period was ~9%. Our results indicate opportunities for improved postoperative care planning after outpatient spinal surgery.

CASE A 66-year-old woman with polymyositis and recurrent urinary tract infections presented with lumbar pain and progressive lower extremity neuropathy. Imaging showed lytic destruction of the vertebral bone from L2 to L4 with extension into adjacent musculature. Histological examination demonstrated Michaelis-Gutmann bodies consistent with malakoplakia. The patient underwent revision T12-sacrum posterior fusion, L2-5 laminectomy, and anterior L3-4 corpectomy, followed by L2-4 anterior stabilization and a 6-week course of ceftriaxone. At 3 months postoperatively, she was asymptomatic without recurrence. CONCLUSION Malakoplakia of bone should be considered in the differential diagnosis of lytic bone lesions and can be effectively treated with surgical debulking with penetrative antibiotics.

Retrospective cohort study of a prospectively collected multi-center database of adult spinal deformity (ASD) patients.We hypothesized that patients undergoing ASD surgery with and without previous spinal cord stimulators (SCS)/ intrathecal medication pumps (ITP) would exhibit increased complication rates but comparable improvement in health-related quality of life.ASD patients sometimes seek pain management with SCS or ITP before spinal deformity correction. Few studies have examined outcomes in this patient population.Patients undergoing ASD surgery and eligible for 2-year follow-up were included. Preoperative radiographs were reviewed for the presence of SCS/ITP. Outcomes included complications, Oswestry Disability Index (ODI), Short Form-36 Mental Component Score, and SRS-22r. Propensity score matching was utilized.In total, of 1034 eligible ASD patients, a propensity score-matched cohort of 60 patients (30 with SCS/ITP, 30 controls) was developed. SCS/ITP were removed intraoperatively in most patients (56.7%, n = 17). The overall complication rate was 80.0% versus 76.7% for SCS/ITP versus control (P 0.2), with similarly nonsignificant differences for intraoperative and infection complications (all P 0.2). ODI was significantly higher among patients with SCS/ITP at baseline (59.2 vs. 47.6, P = 0.0057) and at 2-year follow-up (44.4 vs. 27.7, P = 0.0295). The magnitude of improvement, however, did not significantly differ (P = 0.45). Similar results were observed for SRS-22r pain domain. Satisfaction did not differ between groups at either baseline or follow-up (P 0.2). No significant difference was observed in the proportion of patients with SCS/ITP versus control reaching minimal clinically important difference in ODI (47.6% vs. 60.9%, P = 0.38). Narcotic usage was more common among patients with SCS/ITP at both baseline and follow-up (P 0.05).ASD patients undergoing surgery with SCS/ITP exhibited worse preoperative and postoperative ODI and SRS-22r pain domain; however, the mean improvement in outcome scores was not significantly different from patients without stimulators or pumps. No significant differences in complications were observed between patients with versus without SCS/ITP.Level of Evidence: 3.

Introduction The objective of this study was to examine the effect of obesity on perioperative complications and the cost of surgical management of open ankle fractures. Methods This study examined data from the National Inpatient Sample. The primary outcome variables assessed were occurrence of any complication, complication subtype, length of stay, and total hospital costs. Results Patients with obesity accounted for 10.1% (n = 8.972) of the total cohort. After adjusting for patient and hospital characteristics, patients with obesity exhibited higher odds of any complication, as well as longer length of stay and higher total costs. Conclusion As our understanding of the association between complications and cost of managing open ankle fractures in patients with obesity improves, future research should strive to improve patient outcomes and decrease cost of care through efforts made to prevent complications in patients with obesity.

Smoking is a known risk factor for inferior health outcomes. Retrospective analyses of large datasets may assess whether such risk is manifested or mitigated in clinical practice. Although many risk factor analyses use the National Surgical Quality Improvement Program (NSQIP) and National (Nationwide) Inpatient Sample (NIS), such investigations have seldom been directly compared.NIS and NSQIP datasets were used. Primary outcome measures were perioperative complications. NSQIP complications were stratified based on occurrence before versus after discharge. Multiple logistic regression was employed in adjusted analyses.Among NSQIP (N = 56,145) and NIS (N = 1,311,426) patients, 24.0% and 31.8% were identified as tobacco users, respectively. Before discharge, NSQIP smokers had increased odds of pneumonia (adjusted odds ratio [aOR] = 1.43), postoperative intubation (aOR = 1.40), and sepsis (aOR = 1.71) and decreased odds of pulmonary embolism (aOR = 0.57) (all P0.05). After discharge, NSQIP smokers exhibited increased odds of cardiac arrest (aOR = 2.53) and surgical site infection (aOR = 1.25) and decreased odds of urinary tract infection (aOR = 0.68) and deep venous thrombosis (aOR = 0.61) (all P0.05). In adjusted analysis of NIS data, tobacco users exhibited increased odds of inpatient pneumonia (aOR = 1.57), myocardial infarction (aOR = 1.29), and postoperative intubation (aOR = 1.15) and decreased odds of pulmonary embolism (aOR = 0.80) and deep venous thrombosis (aOR = 0.78) (all P0.05).Patients with a history of tobacco use undergoing spinal fusion were at increased risk of pneumonia and intubation but decreased risk of deep venous thrombosis and pulmonary embolism during the inpatient postoperative stay. After discharge, smokers exhibited increased odds of cardiac arrest and surgical site infection. NIS and NSQIP results were similar, with 9 of 12 outcomes exhibiting identical inpatient conclusions. Qualitative comparison of NIS and NSQIP yields results that offer increased validity over single-source studies.

Introduction: As the opioid epidemic progresses, a better understanding of those at elevated risk of opioid overdose is needed, particularly for populations whose growing risk may be overlooked. Medicare recipients under age 65 (Medicare-disability beneficiaries [MDBs]) are one such population. We sought to analyze characteristics of opioid-overdose hospitalizations among MDBs and quantify the contribution of this population to opioid-overdose hospitalizations overall. Methods: This retrospective cohort study included patients hospitalized for opioid overdose in the National/Nationwide Inpatient Sample from 1998 to 2013. The primary outcome measurements were number and characteristics of discharges, including patient sex, age, race, prescription opioid versus heroin overdose, and comorbidities. Results: MDBs constituted 11.7% of US opioid overdose hospitalizations among those under 65 years of age in 1998; this proportion grew to 24.5% by 2013 ( P P P P P Conclusions: MDBs constitute a substantial and growing proportion of opioid overdose hospitalizations in the United. To prevent opioid overdoses among MDBs, care must be taken to address the unique needs of this population.

BACKGROUND Lateral (ie, coronal) vertebral listhesis may contribute to disability in adult scoliosis patients. OBJECTIVE To assess for a correlation between lateral listhesis and disability among patients with adult scoliosis. METHODS This was a retrospective multi-center analysis of prospectively collected data. Patients eligible for a minimum of 2-yr follow-up and with coronal plane deformity (defined as maximum Cobb angle ≥20o) were included (n = 724). Outcome measures were Oswestry Disability Index (ODI) and leg pain numeric scale rating. Lateral thoracolumbar listhesis was measured as the maximum vertebral listhesis as a percent of the superior endplate across T1-L5 levels. Linear and logistic regression was utilized, as appropriate. Multivariable analyses adjusted for demographics, comorbidities, surgical invasiveness, maximum Cobb angle, and T1-PA. Minimally clinically important difference (MCID) in ODI was defined as 12.8. RESULTS In total, 724 adult patients were assessed. The mean baseline maximum lateral thoracolumbar listhesis was 18.3% (standard deviation 9.7%). The optimal statistical grouping for lateral listhesis was empirically determined to be none/mild (

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.

AI algorithms have shown promise in medical image analysis. Previous studies of ASD clusters have analyzed alignment metrics—this study sought to complement these efforts by analyzing images of sagittal anatomical spinopelvic landmarks. We hypothesized that an AI algorithm would cluster preoperative lateral radiographs into groups with distinct morphology. This was a retrospective review of a multicenter, prospectively collected database of adult spinal deformity. A total of 915 patients with adult spinal deformity and preoperative lateral radiographs were included. A 2 × 3, self-organizing map—a form of artificial neural network frequently employed in unsupervised classification tasks—was developed. The mean spine shape was plotted for each of the six clusters. Alignment, surgical characteristics, and outcomes were compared. Qualitatively, clusters C and D exhibited only mild sagittal plane deformity. Clusters B, E, and F, however, exhibited marked positive sagittal balance and loss of lumbar lordosis. Cluster A had mixed characteristics, likely representing compensated deformity. Patients in clusters B, E, and F disproportionately underwent 3-CO. PJK and PJF were particularly prevalent among clusters A and E. Among clusters B and F, patients who experienced PJK had significantly greater positive sagittal balance than those who did not. This study clustered preoperative lateral radiographs of ASD patients into groups with highly distinct overall spinal morphology and association with sagittal alignment parameters, baseline HRQOL, and surgical characteristics. The relationship between SVA and PJK differed by cluster. This study represents significant progress toward incorporation of computer vision into clinically relevant classification systems in adult spinal deformity. Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

STUDY DESIGN Retrospective case control study. OBJECTIVE To develop predictive models for postoperative outcomes after long segment lumbar posterior spine fusion (LSLPSF). SUMMARY OF BACKGROUND DATA Surgery for adult spinal deformity is effective for treating spine-related disability; however, it has high complication and readmission rates. METHODS Patients who underwent LSLPSF (three or more levels) were identified in State Inpatient Database. Data was queried for discharge-to-facility (DTF), 90-day readmission, and 90-day major medical complications, and demographic, comorbid, and surgical data. Data was partitioned into training and testing sets. Multivariate logistic regression, random forest, and elastic net regression were performed on the training set. Models were applied to the testing set to generate AUCs. AUCs between models were compared using the method by DeLong et al. RESULTS.: 37,852 patients were analyzed. The DTF, 90-day readmission, and 90-day major medical complication rates were 35.4%, 19.0%, and 13.0% respectively. For DTF, the logistic regression AUC was 0.77 versus 0.75 for random forest and 0.76 for elastic net (P

Objective Burnout is a common response to stress and is pervasive among medical students. An increasing proportion of students are taking "gap years" following undergraduate education and before matriculation to medical school. This study evaluates rates of and risk factors for burnout, with a particular focus on students who took gap years. Methods Burnout was measured utilizing the abbreviated Maslach Burnout Inventory. The primary independent variable was whether a student took one or more gap years prior to medical school matriculation. Other variables included age, gender, year in medical school, choice in specialty, and status in a combined baccalaureate-M.D. Program Bivariate and multivariate regression was performed to elucidate relationships between student-level variables and burnout. Results A total of 31.4% of respondents were found to be experiencing high levels of burnout. In multivariate analysis, gap years were independently associated with lower levels of burnout (p = 0.041). Further, burnout decreased in a stepwise fashion with students who took 0 (p = 0.350), 1 (p = 0.192), and 2+ (p = 0.048) gap years. Conclusions Students taking gap years exhibited significantly lower levels of burnout than those who did not. Efforts should be made in pre-medical and medical school curricula to better support students in their paths to medical school.

Spinal emergencies require prompt identification, management, and surgical referral (if needed) from first-line providers. Diagnostic delays from a failure to recognize emergency conditions can lead to adverse patient outcomes. The objective of this study was to understand the proficiency with which first-line providers can recognize and manage spinal conditions, particularly spinal emergencies. This was a cross-sectional analysis of 143 internal medicine, family medicine, emergency care, and neurology questionnaires collected at a single-site academic center. Participants were predominantly physicians (88.1%, n=126), with a smaller percentage of midlevel providers (11.9%, n=17). Only 35.0% (n=50) of respondents felt “very prepared” to handle spinal emergencies. Bivariate analyses revealed interdepartmental differences in clinical knowledge pertaining to the management of lumbar radiculopathy ( P P =.0002), and cervical myelopathy ( P P =.0007) and neurology ( P P P Orthopedics . 2020;43(4):e244–e250.]

This case series examined patients undergoing caudal extension of prior fusion without alteration of the prior upper instrumented vertebra (UIV) to assess patient outcomes and rates of proximal junctional kyphosis (PJK)/proximal junctional failure (PJF).Patients eligible for 2-year minimum follow-up undergoing caudal extension of prior fusion with unchanged UIVs were identified. These patients were evaluated for PJK/PJF, and patient reported outcomes were recorded.In total, 40 patients were included. Mean follow-up duration was 2.2 ± 0.3 years. Patients in this cohort had poor preoperative sagittal alignment (pelvic incidence minus lumbar lordosis [PI-LL] 26.7°, T1 pelvic angle [TPA] 29.0°, sagittal vertical axis [SVA] 93.4 mm) and achieved substantial sagittal correction (ΔSVA -62.2 mm, ΔPI-LL -19.8°, ΔTPA -11.1°) after caudal extension surgery. At final follow-up, there was a 0% rate of PJF among patients undergoing caudal extension of previous fusion without creation of a new UIV, but 27.5% of patients experienced PJK. Patients experienced significant improvement in both the Oswestry Disability Index and Scoliosis Research Society-22r total score at 2 years postoperatively (P0.05). In total, 7.5% (n = 3) of patients underwent further revision, at an average of 1.1 ± 0.54 years after the surgery with unaltered UIV. All 3 of these patients underwent revision for rod fracture with no revisions for PJK/PJF.Patients undergoing caudal extension of previous fusions for sagittal alignment correction have high rates of clinical success, low revision surgery rates, and very low rates of PJF. Minimizing repetitive tissue trauma at the UIV may result in decreased PJF risk because the PJF rate in this cohort of patients with unaltered UIV is below historical PJF rates of patients undergoing sagittal balance correction.

The purpose of this study is to identify patient characteristics that increase risk for unplanned readmission within 30 days of an initial hospital stay after outpatient rotator cuff repair (RCR).A retrospective cohort study was performed utilizing the National Surgical Quality Improvement Program (ACS NSQIP) datasets from 2012 to 2015. Patients were preliminarily included in the study based on the presence of a primary Common Procedural Terminology code for RCR (23410, 23412, 23420, and 29827). Only non-emergent, outpatient, and elective procedures performed on patients with American Society of Anesthesiologists (ASA) ≤4 were considered. The primary outcome variables were 30-day unplanned readmission after outpatient surgery. Secondary analyses were implemented to establish reason and timing of readmission.A total of 18,061 cases were reviewed, and 199 (1%) patients experienced 30-day unplanned readmission. Age ≥80 (OR = 2.13, p = 0.0276), COPD (OR = 1.75, p = 0.0354), hypertension requiring medication (OR = 1.67, p = 0.0027), dialysis (OR = 13.46, p 0.0001) and an ASA classification of 3 (OR = 2.78, p = 0.0143) or ASA 4 (OR = 6.15, p = 0.0012) were identified as major prognosticators for readmission. Female sex was associated with lower odds of readmission (OR = 0.54, p = 0.0001). The most common complications associated with readmission were cardiovascular (29%), infection (19%), and respiratory (17%).The rate of 30-day unplanned inpatient readmission following outpatient RCR using the NSQIP data was found to be 1%, with advanced age and preexisting medical comorbidities contributing to the highest odds of readmission. Cardiovascular, infectious, and respiratory complications contributed to the majority of readmissions. The ability to identify patients with these risk factors will be of utility in optimizing outcomes and cost-effectiveness of RCR.Level III.

Study Design: Retrospective cohort study. Objective: To determine the effects of operative time on postoperative complications in patients age 65 and older undergoing posterior lumbar fusion. Methods: All patients age 65 and older undergoing posterior lumbar fusion were identified in the 2012 to 2015 American College of Surgeons National Surgical Quality Improvement Program database. The primary outcome measures were complications occurring up to 30 days postoperatively, including death, any complication, and complication subtypes. The primary independent variable was operative duration. Both bivariate and multivariate analyses utilized logistic regression and analyzed operative duration as a continuous variable. Statistical significance was considered P < .05. Results: A total of 4947 patients age 65 and older undergoing posterior lumbar fusion were identified. The mean operative time was 3.3 hours (SD 1.7). The overall complication rate was 13.4% (n = 665). In multivariate analysis, each incremental hour of operative time was associated with increased risk of postoperative thromboembolism (odds ratio [OR] = 1.23; 95% confidence interval [CI] = 1.10-1.37), transfusion (OR= 1.25; 95% CI = 1.18-1.32), urinary tract infection (OR = 1.21; 95% CI = 1.10-1.32), and total postoperative complications (OR = 1.22; 95% CI = 1.16-1.27). Conclusion: For patients age 65 and older undergoing posterior lumbar fusion, longer operative time is associated with greater risk for thromboembolism, transfusion, intubation, kidney injury, urinary tract infection, surgical site infection, and overall postoperative complications. This data highlights several specific complications that are influenced by operative time in older patients, and further supports the need for future protocols that seek to safely minimize operative time for posterior lumbar fusion.

DVT is a common complication following lower extremity surgery, occurring in up to 60% of patients undergoing hip fracture surgery without postoperative anticoagulation. The risk of fatal PE continues well-beyond two weeks postoperatively, thus extended DVT prophylaxis beyond 14 days may be warranted. This investigation sought to examine the association between prescription of extended DVT prophylaxis and 30-day postoperative complications following hip fracture surgery.This study utilized the ACS NSQIP Hip Fracture Procedure Targeted dataset, a newly available set of patient variables for 2016. The outcome measures were death, occurrence of any postoperative complication, complication subtype, readmission or reoperation within 30-days postoperatively, and length of stay. The primary independent variable was medical DVT prophylaxis continued 28-days postoperatively ("extended DVT prophylaxis"). The control group contains both patients receiving no prophylaxis and those receiving short-duration prophylaxis. Multivariate stepwise logistic regression was employed to control for potential demographic, comorbidity, and procedural/medical confounding factors.In total, 7533 surgically treated hip fracture patients treated in 2016 were analyzed. Overall, 57.8% of patients (n = 4354) were prescribed extended DVT prophylaxis. On bivariate analysis, prescription of extended DVT prophylaxis was associated with significantly lower incidence of death (7.7% without vs. 2.7% with, p 0.0001) and stroke/CVA (1.4% vs. 0.6%, p = 0.0016). In multivariate analysis, prescription of extended DVT prophylaxis was significantly associated with lower odds of death (OR 0.33, p 0.0001), stroke/CVA (OR 0.44, p = 0.0010), and acute kidney injury (AKI) (OR 0.31, p = 0.0010).This retrospective cohort study of the 2016 ACS NSQIP found that hip fracture surgery patients prescribed ≥28 days of postoperative DVT prophylaxis exhibited 67% lower odds of death and significantly lower rates of AKI and stroke/CVA as compared to those prescribed short-duration prophylaxis. Given the retrospective and uncontrolled nature of this analysis, these results should be interpreted with caution, and additional prospective randomized controlled trials examining the association between extended DVT prophylaxis and postoperative outcomes are warranted. If these observations accurately reflect real-world experience, these data suggest that ≥28 days of DVT prophylaxis following hip fracture surgery should be strongly considered for patients without explicit contraindications.

Study design Retrospective cohort study. Objective To characterize the timing of complications after posterior cervical fusion. Summary of background data Understanding the expected timing of postoperative complications facilitates early diagnosis of potential adverse events and is important for optimizing postoperative care. Though studies have examined the incidence of complications after posterior cervical fusion, no study has characterized the timing of these complications. Methods Patient data in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) dataset with a primary CPT code 22600, corresponding to posterior cervical fusion, was analyzed for demographics, comorbidities, and ten specific complications. Complication timing was assessed, and univariate analysis was performed to investigate the relationship of patient demographic and clinical variables on the development of postoperative complications. Results A total of 2517 patients with a mean age of 59.3 ± 12.5 met inclusion criteria. The overall complication rate was 12.4%. The median day of diagnosis and interquartile range for each complication was: blood transfusion (0.0, 0-0), myocardial infarction (3, 2–7), reintubation (3, 1–9), pneumonia (4, 3–10), deep venous thrombosis (7, 5–16), urinary tract infection (11.5, 5–17.5), sepsis (14, 7–20), pulmonary embolism (14, 8–21), surgical site infection (15, 9–21), and wound dehiscence (15.5, 9–25). Less than 50% deep venous thromboses were diagnosed before discharge, and less than 30% of pulmonary emboli were diagnosed before discharge. On univariate analysis, increased age, decreased functional status, fusing more than one level, current smoker status, diabetes, and CHF were associated with increased complications. Conclusions This timing data is useful to the practicing spine surgeon as it provides a guide for when to expect and investigate for specific complications after posterior cervical procedures. It may aid in the early diagnosis of complications and may also assist in healthcare reimbursement negotiations.

Interhospital competition has been shown to influence the adoption of surgical techniques and approaches, clinical patient outcomes, and health care resource use for select surgical procedures. However, little is known regarding these dynamics as they relate to spine surgery.This investigation sought to examine the relationship between interhospital competitive intensity and perioperative outcomes following lumbar spinal fusion.This study used the Nationwide Inpatient Sample dataset, years 2003, 2006, and 2009.Patients were included based on the presence of the International Classification of Disease, Ninth Edition, Clinical Modification (ICD-9-CM) codes corresponding to lumbar spinal fusion, as well as on the presence of data on the Herfindahl-Hirschman Index (HHI).The outcome measures are perioperative complications, defined using an ICD-9-CM coding algorithm.The HHI, a validated measure of competition within a market, was used to assess hospital market competitiveness. The HHI was calculated based on the hospital cachement area. Multiple regression was performed to adjust for confounding variables including patient age, gender, primary payer, severity of illness score, primary versus revision fusion, anterior versus posterior approach, national region, hospital bed size, location or teaching status, ownership, and year. Perioperative clinical outcomes were assessed based on ICD-9-CM codes with modifications.In total, 417,520 weighted patients (87,999 unweighted records) were analyzed. The mean cachement area HHI was 0.31 (range 0.099-0.724). The average patient age was 55.4 years (standard error=0.194), and the majority of patients were female (55.8%, n=232,727). The majority of procedures were primary spinal fusions (92.7%, n=386,998) and fusions with a posterior-only technique (81.5%, n=340,271). Most procedures occurred in the South (42.5%, n=177,509) or the Midwest (27.0%, n=112,758) regions. In the multiple regression analysis, increased hospital competitive intensity was associated with an increased total complication rate (odds ratio [OR] 1.52, p.0001), device-related complications (OR 1.46, p=.0294), genitourinary complications (OR 2.15, p=.0091), infection (OR 3.48, p.0001), neurologic complications (OR 1.69, p=.0422), total charges (+29%, p=.0034), and inpatient hospital length of stay (LOS) (+16%, p=.0012). The likelihood of complications at state-owned hospitals (OR 2.81, p=.0001) was more highly associated with HHI than at private, non-profit hospitals (OR 1.39, p=.0050). The occurrence of complications at urban teaching hospitals (OR 2.14, p.0001) was generally more associated with HHI than at urban non-teaching hospitals (OR 1.19, p=.2457).Increased interhospital competitive intensity is associated with increased odds of complications, increased total charges, and prolonged LOS following lumbar spine fusion. These differences are generally highest among state-owned and urban teaching hospitals. Differences in outcome related to hospital competition may be due to suboptimal resource allocation. Identifying differences in perioperative outcomes associated with hospital market competition is important in the contemporary environment of health care reimbursement reform and hospital consolidation. Perioperative outcome disparities between highly competitive and minimally competitive areas should be monitored and further studied.

BACKGROUND CONTEXT Adult spinal deformity (ASD) patients experience markedly decreased health-related quality of life along many dimensions. PURPOSE We hypothesized that ASD surgery would be associated with improved work- and school-related productivity, as well as decreased rates of absenteeism. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Only patients eligible for 2-year follow-up were included, and those with a history of previous spinal fusion were excluded. OUTCOME MEASURES The primary outcome measures in this study were SRS-22r questions 9 (“What is your current level of work/school activity?”) and 17 (“In the last 3 months have you taken any days off of work, including household work, or school because of back pain?”). METHODS A repeated measures mixed linear regression was used to analyze responses over time among patients managed operatively (OP) vs nonoperatively (NON-OP). Results were further stratified by baseline employment status, age, SVA, PI-LL, and deformity curve type. RESULTS In total, 1,188 patients were analyzed. Of those, 66.6% (n=792) were managed operatively. The vast majority (78.9%, n=934) were female. Patients were relatively evenly distributed across age groups (27.6% 0-49; 21.1% 50-59; 30.1% 60-69; 21.2% ≥70). At baseline, the mean percentage of activity at work/school was 56.4% (SD 35.4%), and the mean days off from work/school over the past 90 days was 1.6 (SD 1.8). Patients undergoing ASD surgery exhibited an 18.1% absolute increase in work/school productivity at 2-year follow-up vs baseline (p 0.5). Similarly, the OP cohort experienced 1.1 fewer absent days over the past 90 days at 2 years vs baseline (p 0.3). These differences were largely preserved after stratifying by baseline employment status, age group, SVA, PI-LL, and deformity curve type. CONCLUSIONS ASD patients managed operatively exhibited an average increase in work/school productivity of 18.1% and decreased absenteeism of 1.1 per 90 days at 2-year follow-up, while patients managed non-operatively did not exhibit change from baseline. Given the age distribution of patients in this study, these findings should be interpreted as pertaining primarily to obligations at work or within the home. Further study of the direct and indirect economic benefits of ASD surgery to patients is warranted. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Revision surgery is often necessary for adult spinal deformity (ASD) patients. Satisfaction with management is an important component of HRQOL. PURPOSE We hypothesized that patients who underwent multiple revision surgeries following adult spinal deformity correction would exhibit lower satisfaction scores. STUDY DESIGN/SETTING Retrospective cohort study of a prospectively collected multicenter database of ASD patients. PATIENT SAMPLE A total of 668 patients undergoing ASD surgery and eligible for minimum 2-year follow-up were included. OUTCOME MEASURES SRS-22r satisfaction score. METHODS Visits were stratified by occurrence prior to the index surgery (period 0), after the index surgery only (period 1) (ie, never underwent revision or had not yet undergone revision), after first revision only (period 2), and after second revision only (period 3). Patients were further stratified by prior spine surgery before their index surgery. SRS-22r satisfaction scores were evaluated at all periods using multiple linear regression adjusting for age, gender, and CCI. RESULTS In total, 46.6% had prior spine surgery before their index surgery. The overall revision rate was 21.3%. among patients with no spine surgery prior to the index surgery, satisfaction increased from period 0 to 1 (2.8 to 4.3, p 0.3). among patients with multiple revisions, 40% experienced rod fracture, 40% PJK, and 33% pseudarthrosis. CONCLUSIONS ASD patients exhibit decreased satisfaction with subsequent revision. Among patients undergoing primary surgery in our database, this effect is additive for multiple revisions. These results have important implications for surgeons, patients, insurers, hospital administrators, and policymakers. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

OBJECTIVEOptimal patient selection for upper-thoracic (UT) versus lower-thoracic (LT) fusion during adult spinal deformity (ASD) correction is challenging. Radiographic and clinical outcomes following UT versus LT fusion remain incompletely understood. The purposes of this study were: 1) to evaluate demographic, radiographic, and surgical characteristics associated with choice of UT versus LT fusion endpoint; and 2) to evaluate differences in radiographic, clinical, and health-related quality of life (HRQOL) outcomes following UT versus LT fusion for ASD.METHODSRetrospective review of a prospectively collected multicenter ASD database was performed. Patients with ASD who underwent fusion from the sacrum/ilium to the LT (T9–L1) or UT (T1–6) spine were compared for demographic, radiographic, and surgical characteristics. Outcomes including proximal junctional kyphosis (PJK), reoperation, rod fracture, pseudarthrosis, overall complications, 2-year change in alignment parameters, and 2-year HRQOL metrics (Lumbar Stiffness Disability Index, Scoliosis Research Society-22r questionnaire, Oswestry Disability Index) were compared after controlling for confounding factors via multivariate analysis.RESULTSThree hundred three patients (169 LT, 134 UT) were evaluated. Independent predictors of UT fusion included greater thoracic kyphosis (odds ratio [OR] 0.97 per degree, p = 0.0098), greater coronal Cobb angle (OR 1.06 per degree, p < 0.0001), and performance of a 3-column osteotomy (3-CO; OR 2.39, p = 0.0351). While associated with longer operative times (ratio 1.13, p < 0.0001) and greater estimated blood loss (ratio 1.31, p = 0.0018), UT fusions resulted in greater sagittal vertical axis improvement (−59.5 vs −41.0 mm, p = 0.0035) and lower PJK rates (OR 0.49, p = 0.0457). No significant differences in postoperative HRQOL measures, reoperation, or overall complication rates were detected between groups (all p > 0.1).CONCLUSIONSGreater deformity and need for 3-CO increased the likelihood of UT fusion. Despite longer operative times and greater blood loss, UT fusions resulted in better sagittal correction and lower 2-year PJK rates following surgery for ASD. While continued surveillance is necessary, this information may inform patient counseling and surgical decision-making.

To compare postoperative complications, rates of revision, and opioid use of those who undergo shoulder arthroscopy with and without previous anterior cervical discectomy and fusion (ACDF).The PearlDiver database from 2007 to 2017 was used to query all patients who underwent shoulder arthroscopy as determined by Current Procedural Terminology (CPT). Patients were then separated among those who had a previous instance of ACDF and those who did not as filtered by CPT. Postoperative complications within 30 days, readmission rates, opioid use, and revision procedures were assessed for each cohort using a mix of International Classification of Diseases Ninth and Tenth Revision Clinical Modification codes, CPT, as well as generic drug codes.A total of 91,029 patients undergoing shoulder arthroscopy were identified, of whom 1,267 (1.4%) had a history of ACDF. Compared with patients without previous ACDF, patients with a history of ACDF had significantly greater respiratory complication rates (1.3% vs 0.5%: adjusted odds ratio [aOR] 2.16, 95% confidence interval [CI]1.30-3.59, P = .003), 30-day complication rates (3.7% vs 2.2%: aOR 1.48, 95% CI 1.10-1.99, P = .011), 1-year revision rates (15.2% vs 7.7%: aOR 2.00, 95% CI 1.71-2.33, P.0001), and greater opioid use at 1 month, 3 months, 6 months, and 12 months (P.0001).This study revealed that patients who undergo shoulder arthroscopy with a history of ACDF are twice as likely to undergo revision arthroscopy within 2 years of surgery and are at an increased risk of complications within 30 days postoperatively as well as prolonged opioid use compared with those without a history of ACDF. With these findings, both spine and shoulder surgeons should aim to be more aware of surgical history, especially of the cervical spine, to better counsel patients' clinical course and expected outcomes following shoulder arthroscopy.III, retrospective cohort study.

Study Design: Retrospective cohort. Objectives: Parkinson’s disease (PD) is a neurodegenerative condition associated with significant morbidity and mortality. PD patients often develop spinal conditions and are known to have high complication rates following surgery. This study evaluated the outcomes of lumbar fusion surgery in patients with PD using a large, public, national database. Methods: The Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) was used to identify elective lumbar spinal fusion patients with and without PD for the years 2000 to 2012. PD patients were matched with non-PD controls for comorbidity and age using propensity score matching. Univariable and multivariable logistic regression were used to determine the relationship between PD and surgical outcomes in the matched cohort. Results: A total of 231 351 elective lumbar fusion patients were examined, of which 1332 had PD. Before matching, elective lumbar fusion patients with PD were significantly older (P < .001) and more likely male (P < .001) compared with non-PD patients. In the matched cohort, PD was associated with increased length of stay (6.91 vs 5.78 days) (P < .001) and total hospital charges ($129 212.40 vs $110 324.40) (P < .001). There was no significant difference in overall in-hospital complication rate between PD patients and matched non-PD patients (22.3% vs 21.4%) (P = .524). Conclusions: Analysis demonstrated significant increases in length and cost of hospitalization for elective lumbar spinal fusion in patients with PD. However, inpatient complication rates in PD patients were not significantly increased. As a growing number of PD patients undergo elective spine surgery, further studies are needed to optimize operative planning. Further study is needed to assess the long-term outcomes of lumbar spinal fusion in PD.

Acute carpal tunnel syndrome (CTS) may occur concomitantly with distal radius fracture (DRF) and is often managed with carpal tunnel release (CTR). Carpal tunnel syndrome may also develop postoperatively after DRF fixation. The authors sought to determine the rate of CTS with DRF, prophylactic CTR, and postoperative development of CTS. Furthermore, they also sought to identify predictors of these. The Nationwide Inpatient Sample database was queried (2002 to 2014) to identify adult inpatients undergoing surgical fixation of DRFs. They were segregated by the presence of CTS and further stratified by the timing of CTR in relation to DRF fixation. Those with a CTS diagnosis undergoing CTR on the same day as or prior to DRF fixation were classified as having CTS concomitantly. Patients undergoing CTR without a CTS diagnosis were considered prophylactically released. Carpal tunnel releases on any day after fracture fixation were considered complications. The authors identified 275,052 inpatients who had fixation of DRFs. Of these, 11,816 patients (4.3%) had CTS concomitantly. A total of 530 patients developed CTS after their DRF fixation (0.3%). Of those without CTS, 4420 patients (1.6%) underwent prophylactic CTR. Male sex, age younger than 50 years, and polytrauma status were associated with concomitant CTS and prophylactic CTR. Age younger than 50 years and polytrauma status were associated with postoperative development of CTS. The authors identified the rate of concomitant CTS, prophylactic CTR, and CTS developing postoperatively in inpatients undergoing DRF fixation. As early recognition and treatment optimizes outcomes after acute CTS, these data draw attention to the high rate of CTS and may be useful to surgeons treating patients with DRFs. [ Orthopedics . 2019; 42(4):227–234.]

Recent population-level increases in intravenous drug abuse (IVDA) may contribute to incidence of spinal infection. The aim of this study was to evaluate national trends of spinal infections and evaluate effect of IVDA on outcomes in operative management of spinal infection.Using the National (Nationwide) Inpatient Sample database for 2002-2014, all patients undergoing spinal decompression or fusion for treatment of spinal infection were evaluated. Inpatient outcomes included length of stay, total cost, complications, discharge to facility, reoperations, and inpatient mortality. Bivariate and multivariate logistic regression analyses were performed to compare patients with IVDA and patients without IVDA.A total of 60,964 patients undergoing surgical management of spinal infection were identified. Number of surgically managed spine infections increased from 2002 to 2014 (P0.0001). Proportion of surgically managed spine infections associated with IVDA increased from 3.3% in 2002 to 14.0% in 2014 (P0.0001). IVDA was associated with increased hospital length of stay (odds ratio = 1.38; 95% confidence interval, 1.32-1.45; P0.0001) and greater total charges (odds ratio = 1.23; 95% confidence interval, 1.17-1.29; P0.0001). No other significant differences between groups were noted.From 2002 to 2014 in the United States, the incidence of operatively treated spine infections increased 227.9%, and the proportion of cases associated with IVDA significantly increased. Patients with IVDA had a longer mean length of stay and increased inpatient cost of care but were not at increased risk for complication, reoperation, or mortality. These findings are important for surgeons, internists, hospitals, and insurers to ensure proper resource allocation in treating these at-risk patients.

BACKGROUND CONTEXT AI algorithms have shown substantial promise in medical image analysis. Previous studies of ASD clusters have analyzed alignment metrics – this study sought to complement these efforts by analyzing images of anatomical landmarks. PURPOSE We hypothesized that a neural-network-based artificial intelligence (AI) algorithm would cluster preoperative lateral radiographs of into groups with distinct morphology. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE A total of 915 patients with adult spinal deformity and preoperative lateral radiographs. OUTCOME MEASURES Schwab modifiers for SVA and PI-LL, three-column osteotomy, upper instrumented vertebrae, baseline Oswestry Disability Index, and 2-year likelihood of reaching MCID in ODI (set at -12.8). Proximal junctional kyphosis and proximal junctional failure were defined using previously published radiographic criteria. METHODS Vertebral locations for C3-L5, sacral endplate, and femoral heads were measured on lateral radiographs. Pixel locations were used to create a black-and-white overlay to the image, which was subsequently standardized for size and position using the femoral heads and sacral endplate. These images were used to train a self-organizing map (SOM). SOMs are a form of artificial neural network frequently employed in unsupervised classification tasks. RESULTS In total, 915 preoperative lateral radiographs were analyzed. A 2 × 3, toroidal SOM was trained. The mean spine shape was plotted for each cluster. Alignment, surgical characteristics, and outcomes were compared between clusters. Clusters C and D exhibited a particularly high proportion of patients with optimal (ie, modifier 0) values of PI-LL (65.0% and 68.5%) and SVA (72.8% and 53.1%). Conversely, clusters B, E, and F tended to have poor (ie, modifier ++) PI-LL (74.8%, 66.9%, and 74.6%) and SVA (75.5%, 48.6%, and 58.7%). 3-CO was most common among cluster A (26.8%), cluster B (32.6%), and cluster F (32.7%). UIV at T7-T12 was most common among cluster B (51.1%) and cluster F (60.3%). ODI CONCLUSIONS This study developed a self-organizing map that clustered preoperative lateral radiographs of ASD patients into groups with highly distinct overall spinal morphology. These clusters predicted alignment, surgical characteristics, and HRQOL. Further studies of this classification approach will expand to compare pre- and postoperative radiographs. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Proximal junctional failure (PJF) is a common and particularly adverse complication of adult spinal deformity (ASD) surgery. There is evidence that the rigidity of posterior spinal constructs may impact risk of PJF. PURPOSE We hypothesized that lower mean screws per level and decreased rod stiffness would be associated with lower incidence of PJF. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Patients with ASD and 2-year minimum follow-up were included. Only patients undergoing fusion of ≥5 levels, and with LIV at the sacro-pelvis were included. Patients undergoing revision surgery were excluded. In total, 420 patients were analyzed. OUTCOME MEASURES The primary outcome variable was PJF, defined using previously published radiographic criteria (PJ angle >28°and ∆PJ angle >22°, and ≥8mm/≥3mm listhesis at upper thoracic / thoracolumbar levels, respectively). METHODS The primary independent variables were the mean number of screws per level fused analyzed with a cutoff of 1.8 (determined by ROC analysis) and rod material/diameter. Multivariable logistic regression was utilized to investigate confounding factors, including age, history of osteoporosis, BMI, gender, CCI, preoperative Schwab modifiers, preoperative TPA, postoperative change in lumbar lordosis, upper instrumented vertebra, osteotomy, approach, UIV type (ie, pedicle screw vs other), and number of levels fused. RESULTS Of the total patients, 78.8% were female. PJF occurred in 14.1% of patients. The mean screws per level was 1.7 (SD 0.2), and 57.6% of patients had 0.2) were not significantly associated with PJF. Screw density specifically adjacent to the UIV was not related to PJF (p>0.2). CONCLUSIONS Among ASD patients undergoing long-segment primary fusion to the pelvis, the risk of PJF was lower among patients with FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

To examine the approximated financial outcomes of physicians by specialty and to determine whether these correlate with mean USMLE Step 1 scores.Specialty-specific data from the Association of American Medical Colleges Careers in Medicine website were analyzed for total length of training, mean USMLE Step 1 scores, average hours worked per week, and median clinical practice salary for physicians. Hourly wage and estimated net worth at retirement were calculated. Coefficients of determination (R2) were calculated to evaluate the relationships between hourly wage, annual salary, and estimated net worth at retirement with competitiveness as measured by USMLE Step 1 scores of matched residents.Across all 37 specialties studied, the mean hourly wage was $136 ± $40, ranging from $78 (Geriatrics) to $249 (Neurosurgery). Mean weekly hours worked across all specialties was 54.6 ± 6.4, ranging from 43.4 (Pediatric Emergency Medicine) to 71.1 (Vascular Surgery). At retirement, the mean estimated net worth for all physicians was $4,517,600 ± $1,793,095, ranging from $1,927,779 (ChildAdolescent Psychiatry) to $8,947,885 (Neurosurgery). Step 1 scores, as a marker of specialty competiveness, correlate with specialty compensation - the strongest association was with hourly wage (R2 = 0.6678), then annual salary (R2 = 0.6424), and finally by estimated net worth at retirement (R2 = 0.6158).In this study, mean Step 1 scores for each medical specialty were positively correlated with compensation, including absolute salary, hourly wage and estimated net worth at retirement.

Spinal epidural abscesses (SEA) can be challenging to diagnose and may result in serious adverse outcomes sometimes leading to neurologic compromise, sepsis, and even death. While SEA may lead to litigation for healthcare providers, little is known about the medicolegal factors predicting case outcome of SEA related litigation cases. Three large medicolegal databases (VerdictSearch, Westlaw, and LexisNexis) were queried for SEA-related malpractice cases. Plaintiff (patient) age, sex, previous infection history and clinical outcomes such as residual paraplegia/quadriplegia, and delay in diagnosis or treatment were examined. The relationship between these variables and the proportion of plaintiff rulings and size of indemnity payments were assessed. Of the 135 cases that met inclusion criteria, 29 (21.5%) settled, 59 (43.7%) resulted in a defendant ruling, and 47 (34.8%) resulted in a plaintiff ruling. Mean award for plaintiff rulings was $4,291,400 (95% CI, $5,860,129 to $2,722,671), which was significantly larger than mean awards for cases that settled out of court, $2,324,170 (95% CI, $3,206,124 to $1,442,217) (P0.05). In contrast, plaintiff verdicts were more common for patients who became paraplegic or quadriplegic (P