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Objective: On August 31, 2017, the state of Ohio implemented legislation limiting the dosage and duration of opioid prescriptions. Despite the widespread adoption of such restrictions, few studies have investigated the effects of these reforms on opioid prescribing and patient outcomes. In the present study, the authors aimed to evaluate the effect of recent state-level reform on opioid prescribing, patient-reported outcomes (PROs), and postoperative emergency department (ED) visits and hospital readmissions after elective lumbar decompression surgery., Methods: This study was a retrospective cohort study of patients who underwent elective lumbar laminectomy for degenerative disease at one of 5 hospitals within a single health system in the years prior to and after the implementation of the statewide reform (September 1, 2016-August 31, 2018). Patients were classified according to the timing of their surgery relative to implementation of the prescribing reform: before reform (September 1, 2016-August 31, 2017) or after reform (September 1, 2017- August 31, 2018). The outcomes of interest included total outpatient opioids prescribed in the 90 days following discharge from surgery as measured in morphine-equivalent doses (MEDs), total number of opioid refill prescriptions written, patient-reported pain at the first postoperative outpatient visit as measured by the Numeric Pain Rating Scale, improvement in patient-reported health-related quality of life as measured by the Patient-Reported Outcomes Measurement Information System-Global Health (PROMIS-GH) questionnaire, and ED visits or hospital readmissions within 90 days of surgery., Results: A total of 1031 patients met the inclusion criteria for the study, with 469 and 562 in the before- and after-reform groups, respectively. After-reform patients received 26% (95% CI 19%-32%) fewer MEDs in the 90 days following discharge compared with the before-reform patients. No significant differences were observed in the overall number of opioid prescriptions written, PROs, or postoperative ED or hospital readmissions within 90 days in the year after the implementation of the prescribing reform., Conclusions: Patients undergoing surgery in the year after the implementation of a state-level opioid prescribing reform received significantly fewer MEDs while reporting no change in the total number of opioid prescriptions, PROs, or postoperative ED visits or hospital readmissions. These results demonstrate that state-level reforms placing reasonable limits on opioid prescriptions written for acute pain may decrease patient opioid exposure without negatively impacting patient outcomes after lumbar decompression surgery.

Objective: Iatrogenic spine injury remains one of the most dreaded complications of pedicle subtraction osteotomies (PSOs) and spine deformity surgeries. Thus, intraoperative multimodal monitoring (IOM), which has the potential to provide real-time feedback on spinal cord signal transmission, has become the gold standard in such operations. However, while the benefits of IOM are well established in PSOs of the thoracic spine and scoliosis surgery, its utility in PSOs of the lumbar spine has not been robustly documented. The authors' aim was to determine the impact of IOM on outcomes in patients undergoing PSO of the lumbar spine., Methods: All patients older than 18 years who underwent lumbar PSOs at the authors' institution from 2007 to 2017 were analyzed via retrospective chart review and categorized into one of two groups: those who had IOM guidance and those who did not. Perioperative complications were designated as the primary outcome measure and postoperative quality of life (QOL) scores, specifically the Parkinson's Disease Questionnaire-39 (PDQ-39) and Patient Health Questionnaire-9 (PHQ-9), were designated as secondary outcome measures. Data on patient demographics, surgical and monitoring parameters, and outcomes were gathered, and statistical analysis was performed to compare the development of perioperative complications and QOL scores between the two cohorts. In addition, the proportion of patients who reached minimal clinically important difference (MCID), defined as an increase of 4.72 points in the PDQ-39 score or a decrease of 5 points in the PHQ-9 score, in the two cohorts was also determined., Results: A total of 95 patients were included in the final analysis. IOM was not found to significantly impact the development of new postoperative deficits (p = 0.107). However, the presence of preoperative neurological comorbidities was found to significantly correlate with postoperative neurological complications (p = 0.009). Univariate analysis showed that age was positively correlated with MCID achievement 3 months after surgery (p = 0.018), but this significance disappeared at the 12-month postoperative time point (p = 0.858). IOM was not found to significantly impact MCID achievement at either the 3- or 12-month postoperative period as measured by PDQ-39 (p = 0.398 and p = 0.156, respectively). Similarly, IOM was not found to significantly impact MCID achievement at either the 3- or 12-month postoperative period, as measured by PHQ-9 (p = 0.230 and p = 0.542, respectively). Multivariate analysis showed that female sex was significantly correlated with MCID achievement (p = 0.024), but this significance disappeared at the 12-month postoperative time point (p = 0.064). IOM was not found to independently correlate with MCID achievement in PDQ-39 scores at either the 3- or 12-month postoperative time points (p = 0.220 and p = 0.097, respectively)., Conclusions: In this particular cohort, IOM did not lead to statistically significant improvement in outcomes in patients undergoing PSOs of the lumbar spine (p = 0.220). The existing clinical equipoise, however, indicates that future studies in this arena are necessary to achieve systematic guidelines on IOM usage in PSOs of the lumbar spine.

Objective: Under the Bundled Payments for Care Improvement (BPCI) initiative, Medicare reimburses for lumbar fusion without adjusting for underlying pathology. However, lumbar fusion is a widely used technique that can treat both degenerative and traumatic pathologies. In other surgical cohorts, significant heterogeneity exists in resource use when comparing procedures for traumatic versus degenerative pathologies. If the same were true for lumbar fusion, BPCI would create a financial disincentive to treat specific patient populations. The goal of this study was to compare hospital resource use for lumbar fusion between 2 patient populations: patients with spondylolisthesis and patients with lumbar vertebral fracture., Methods: The authors compared the hospital resource use of two lumbar fusion cohorts that BPCI groups into the same payment bundle for lumbar fusion: patients with spondylolisthesis and patients with lumbar vertebral fracture. National Inpatient Sample data from 2013 were queried for patients who underwent lumbar fusion for lumbar vertebral fracture or spondylolisthesis. Hospital resource use was measured using length of stay (LOS), direct hospital costs, and odds of discharge to a post-acute care facility and compared using multivariable linear and logistic regression. All models adjusted for patient demographics, 29 comorbidities, and hospital characteristics., Results: After adjusting for patient demographics, insurance status, hospital characteristics, and 29 comorbidities, spondylolisthesis patients had a mean LOS that was 36% shorter (95% CI 26%-44%, p < 0.0001), a mean cost that was 13% less (95% CI 3.7%-21%, p < 0.0001), and 3.2 times greater odds of being discharged home (95% CI 2.5-5.4, p < 0.0001) than lumbar vertebral fracture patients., Conclusions: Under the proposed DRG (diagnosis-related group)-based BPCI, hospitals would be reimbursed the same amount for lumbar fusion regardless of the diagnosis. However, compared with fusion for spondylolisthesis, fusion for lumbar vertebral fracture was associated with longer LOS, greater direct hospital costs, and increased likelihood of being discharged to a post-acute care facility. These findings suggest that the BPCI episode of care for lumbar fusion dis-incentivizes treatment of trauma patients.

Objective: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys, completed by patients following an inpatient stay, are utilized to assess patient satisfaction and quality of the patient experience. HCAHPS results directly impact hospital and provider reimbursements. While recent work has demonstrated that pre- and postoperative factors can affect HCAHPS results following lumbar spine surgery, little is known about how these results are influenced by hospital length of stay (LOS). Here, the authors examined HCAHPS results in patients with LOSs greater or less than expected following lumbar spine surgery to determine whether LOS influences survey scores after these procedures., Methods: The authors conducted a retrospective review of HCAHPS surveys, patient demographics, and outcomes following lumbar spine surgery at a single institution. A total of 391 patients who had undergone lumbar spine surgery and had completed an HCAHPS survey in the period between 2013 and 2015 were included in this analysis. Patients were divided into those with a hospital LOS equal to or less than the expected (LTE-LOS) and those with a hospital LOS longer than expected (GTE-LOS). Expected LOS was based on the University HealthSystem Consortium benchmarks. Nineteen questions from the HCAHPS survey were examined in relation to patient LOS. The primary outcome measure was a comparison of "top-box" ("9-10" or "always or usually") versus "low-box" ("1-8" and "somewhat or never") scores on the HCAHPS questions. Secondary outcomes of interest were whether the comorbid conditions of cancer, chronic renal failure, diabetes, coronary artery disease, hypertension, stroke, or depression occurred differently with respect to LOS. Statistical analysis was performed using Fisher's exact test for the 2 × 2 contingency tables and the chi-square test for categorical variables., Results: Two hundred fifty-seven patients had an LTE-LOS, whereas 134 patients had a GTE-LOS. The only statistically significant difference in preoperative characteristics between the patient groups was hypertension, which correlated to a shorter LOS. A GTE-LOS was associated with a decreased likelihood of a top-box score for the HCAHPS survey items on doctor listening and pain control., Conclusions: Here, the authors report a decreased likelihood of top-box responses for some HCAHPS questions following lumbar spine surgery if LOS is prolonged. This study highlights the need to further examine the factors impacting LOS, identify patients at risk for long hospital stays, and improve mechanisms to increase the quality and efficiency of care delivered to this patient population.

OBJECTIVEUse of surgical site drains following posterior cervical spine surgery is variable, and its impact on outcomes remains controversial. Studies of drain use in the lumbar spine have suggested that drains are not associated with reduction of reoperations for wound infection or hematoma. There is a paucity of studies examining this relationship in the cervical spine, where hematomas and infections can have severe consequences. This study aims to examine the relationship between surgical site drains and reoperation for wound-related complications following posterior cervical spine surgery.METHODSThis study is a multicenter retrospective review of 1799 consecutive patients who underwent posterior cervical decompression with instrumentation at 4 tertiary care centers between 2004 and 2016. Demographic and perioperative data were analyzed for associations with drain placement and return to the operating room.RESULTSOf 1799 patients, 1180 (65.6%) had a drain placed. Multivariate logistic regression analysis identified history of diabetes (OR 1.37, p = 0.03) and total number of levels operated (OR 1.32, p < 0.001) as independent predictors of drain placement. Rates of reoperation for any surgical site complication were not different between the drain and no-drain groups (4.07% vs 3.88%, p = 0.85). Similarly, rates of reoperation for surgical site infection (1.61% vs 2.58%, p = 0.16) and hematoma (0.68% vs 0.48%, p = 0.62) were not different between the drain and no-drain groups. However, after adjusting for history of diabetes and the number of operative levels, patients with drains had significantly lower odds of returning to the operating room for surgical site infection (OR 0.48, p = 0.04) but not for hematoma (OR 1.22, p = 0.77).CONCLUSIONSThis large study characterizes current practice patterns in the utilization of surgical site drains during posterior cervical decompression and instrumentation. Patients with drains placed did not have lower odds of returning to the operating room for postoperative hematoma. However, the authors' data suggest that patients with drains may be less likely to return to the operating room for surgical site infection, although the absolute number of infections in the entire population was small, limiting the analysis.

OBJECTIVE The middle clinoid process (MCP) is a bony projection that extends from the sphenoid bone near the lateral margin of the sella turcica. The varied prevalence and morphological features of the MCP in populations stratified by age, race, and sex are unknown; however, the knowledge of its anatomy and preoperative recognition on CT scans can aid greatly in complication avoidance and management. The aim of this study was to further illustrate the surgical anatomy of the parasellar region and to quantify the incidence of MCP and caroticoclinoid rings (CCRs) in dried preserved human anatomical specimens. METHODS The presence, dimensions, morphological classification (incomplete, contact, and CCR), and intracranial relations of the MCP were measured in 2726 dried skull specimens at the Hamann-Todd Osteological Collection at the Cleveland Museum of Natural History. Specific morphometric data points were recorded from each of these hemiskulls, and categorized based on age, sex, and ethnicity. Linear and logistic regressions were used to determine associations between explanatory variables and MCP morphology. Computed tomography scans of the skull specimens were obtained to explore radiological landmarks for different types of MCPs. Illustrative intraoperative videos were also analyzed in the light of these crucial surgical landmarks. RESULTS The sample included 2250 specimens from males and 476 from females. Specimens were classified as either "white" (60.5%) or "black" (39.2%). An MCP was found in 42% of specimens, with 60% of those specimens presenting bilaterally. Fully ossified CCR comprised 27% of all MCPs, and contact (defined as contact without ossification between MCP and anterior clinoid process) comprised 4% of all MCPs. White race (relative to black race) and increasing age were significant predictors of MCP presence (p < 0.001). White race was significantly associated with greater average MCP height (p < 0.001). Among skulls with CCR, both male sex and older age (> 70 years relative to < 50 years) were associated with increased CCR diameter (p < 0.001). No other significant predictors or associations were observed. The CT scans of skulls replicated and validated the authors' morphometric observations on incomplete, contact, and CCR patterns adequately. The surgical strategies of clinoid bone removal are validated, with appropriate video illustrations. CONCLUSIONS Variations in the patterns of bony MCPs can pose a significant risk for injury to the internal carotid artery during parasellar procedures, especially those involving clinoidectomy and optic strut drilling. Understanding parasellar anatomy, especially on skull-base CT imaging, may be integral to surgical planning and preoperative risk counseling in both transcranial and extended endonasal procedures, as well as to preparing for complications management perioperatively.

OBJECTIVE The Patient Experience of Care, composed of 9 dimensions derived from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, is being used by the Centers for Medicare & Medicaid Services to adjust hospital reimbursement. Currently, there are minimal data on how scores on the constituent HCAHPS items impact the global dimension of satisfaction, the Overall Hospital Rating (OHR). The purpose of this study was to determine the key drivers of overall patient satisfaction in the setting of inpatient lumbar spine surgery. METHODS Demographic and preoperative patient characteristics were obtained. Patients selecting a top-box score for OHR (a 9 or 10 of 10) were considered to be satisfied with their hospital experience. A baseline multivariable logistic regression model was then developed to analyze the association between patient characteristics and top-box OHR. Then, multivariable logistic regression models adjusting for patient-level covariates were used to determine the association between individual components of the HCAHPS survey and a top-box OHR. RESULTS A total of 453 patients undergoing lumbar spine surgery were included, 80.1% of whom selected a top-box OHR. Diminishing overall health status (OR 0.63, 95% CI 0.43-0.91) was negatively associated with top-box OHR. After adjusting for potential confounders, the survey items that were associated with the greatest increased odds of selecting a top-box OHR were: staff always did everything they could to help with pain (OR 12.5, 95% CI 6.6-23.7), and nurses were always respectful (OR 11.0, 95% CI 5.3-22.6). CONCLUSIONS Patient experience of care is increasingly being used to determine hospital and physician reimbursement. The present study analyzed the key drivers of patient experience among patients undergoing lumbar spine surgery and found several important associations. Patient overall health status was associated with top-box OHR. After adjusting for potential confounders, staff always doing everything they could to help with pain and nurses always being respectful were the strongest predictors of overall satisfaction in this population. These findings highlight opportunities for quality improvement efforts in the spine care setting.

OBJECTIVE The aim of this study was to systematically review the literature on reported outcomes following decompression surgery for spinal metastases. METHODS The authors conducted MEDLINE, Scopus, and Web of Science database searches for studies reporting clinical outcomes and complications associated with decompression surgery for metastatic spinal tumors. Both retrospective and prospective studies were included. After meeting inclusion criteria, articles were categorized based on the following reported outcomes: survival, ambulation, surgical technique, neurological function, primary tumor histology, and miscellaneous outcomes. RESULTS Of the 4148 articles retrieved from databases, 36 met inclusion criteria. Of those included, 8 were prospective studies and 28 were retrospective studies. The year of publication ranged from 1992 to 2015. Study size ranged from 21 to 711 patients. Three studies found that good preoperative Karnofsky Performance Status (KPS ≥ 80%) was a significant predictor of survival. No study reported a significant effect of time-to-surgery following the onset of spinal cord compression symptoms on survival. Three studies reported improvement in neurological function following surgery. The most commonly cited complication was wound infection or dehiscence (22 studies). Eight studies reported that preoperative ambulatory or preoperative motor status was a significant predictor of postoperative ambulatory status. A wide variety of surgical techniques were reported: posterior decompression and stabilization, posterior decompression without stabilization, and posterior decompression with total or subtotal tumor resection. Although a wide range of functional scales were used to assess neurological outcomes, four studies used the American Spinal Injury Association (ASIA) Impairment Scale to assess neurological function. Four studies reported the effects of radiation therapy and local disease control for spinal metastases. Two studies reported that the type of treatment was not significantly associated with the rate of local control. The most commonly reported primary tumor types included lung cancer, prostate cancer, breast cancer, renal cancer, and gastrointestinal cancer. CONCLUSIONS This study reports a systematic review of the literature on decompression surgery for spinal metastases. The results of this study can help educate surgeons on the previously published predictors of outcomes following decompression surgery for metastatic spinal disease. However, the authors also identify significant gaps in the literature and the need for future studies investigating the optimal practice with regard to decompression surgery for spinal metastases.