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• For patients with coronary artery disease, the two most common options for intervention are a vascular stent or a coronary artery bypass graft. • Although less invasive, vascular stents may pose a long-term risk for patients undergoing further invasive procedures such as elective spine surgery. • This study aimed to provide surgeons with insight on possible major complications for elective spine surgery patients with a history of CAD. • When assessing patients with a history of coronary artery disease for elective spine fusion surgery, surgeons should be cautious of the significant risk of major complications associated with vascular stents. Revascularization is a more effective intervention to reduce future postop complications. Patients undergoing elective spine fusion surgery were isolated in the PearlDiver database. Patients were stratified by having previous history of vascular stenting (Stent), coronary artery bypass graft (CABG), and no previous heart procedure (No-HP). Means comparison tests (chi-squared and independent samples t-tests, as appropriate) compared differences in demographics, diagnoses, and comorbidities. Binary logistic regression assessed the odds of 30-day and 90-day postoperative (postop) complications associated with each heart procedure (Odds Ratio [95 % confidence interval]). Statistical significance was set p < 0.05. 731,173 elective spine fusion patients included. Overall, 8,401 pts underwent a CABG, 24,037 pts Stent, and 698,735 had No-HP prior to spine fusion surgery. Compared to Stent and No-HP patients, CABG patients had higher rates of morbid obesity, chronic kidney disease, and diabetes (p < 0.001 for all). Meanwhile, stent patients had higher rates of PVD, hypertension, and hyperlipidemia (all p < 0.001). 30-days post-op, CABG patients had significantly higher complication rates including pneumonia, CVA, MI, sepsis, and death compared to No-HP (all p < 0.001). Stent patients vs. No-HF had higher 30-day post-op complication rates including pneumonia, CVA, MI, sepsis, and death. Furthermore, adjusting for age, comorbidities, and sex Stent was significantly predictive of a MI 30-days post-op (OR: 1.90 [1.53–2.34], P < 0.001). Additionally, controlling for levels fused, stent patients compared to CABG patients had 1.99x greater odds of a MI within 30-days (OR: 1.99 [1.26–3.31], p = 0.005) and 2.02x odds within 90-days postop (OR: 2.2 [1.53–2.71, p < 0.001). With regards to spine surgery, coronary artery bypass graft remains the gold standard for risk reduction. Stenting does not appear to minimize risk of experiencing a post-procedure cardiac event as dramatically as CABG. [ABSTRACT FROM AUTHOR]

• Little literature assesses mFI-5 as a predictor for outcomes in ASD patients. • An mFI-5 score of 1 or 2 was associated with 30-day reoperations. • An mFI-5 score of 1 or 2 was associated with 30-day related and any readmissions. • This supports mFI-5 as a possible predictor for adverse postoperative outcomes. There is limited research regarding the association between the mFI-5 and postoperative complications among adult spinal deformity (ASD) patients. Using the National Surgical Quality Improvement Project (NSQIP) database, patients with Current Procedural Terminology (CPT) codes for > 7-level fusion or < 7-level fusion with International Classification of Diseases, Ninth Revision (ICD-9) codes for ASD were identified between 2008 and 2016. Univariate analyses with post-hoc Bonferroni correction for demographics and preoperative factors were performed. Logistic regression assessed associations between mFI-5 scores and 30-day post-operative outcomes. 2,120 patients met criteria. Patients with an mFI-5 score of 4 or 5 were excluded, given there were<20 patients with those scores. Patients with mFI-5 scores of 1 and 2 had increased 30-day rates of pneumonia (3.5 % and 4.3 % vs 1.6 %), unplanned postoperative ventilation for > 48 h (3.1 % and 4.3 % vs 0.9 %), and UTIs (4.4 % and 7.4 % vs 2.0 %) than patients with a score of 0 (all, p < 0.05). Logistic regression revealed that compared to an mFI-5 of 0, a score of 1 was an independent predictor of 30-day reoperations (OR = 1.4; 95 % CI 1.1–18). A score of 2 was an independent predictor of overall (OR = 2.4; 95 % CI 1.4–4.1) and related (OR = 2.2; 95 % CI 1.2–4.1) 30-day readmissions. A score of 3 was not predictive of any adverse outcome. The mFI-5 score predicted complications and postoperative events in the ASD population. The mFI-5 may effectively predict 30-day readmissions. Further research is needed to identify the benefits and predictive value of mFI-5 as a risk assessment tool. [ABSTRACT FROM AUTHOR]

The cellular mechanisms underlying excess scar tissue formation in arthrofibrosis following total knee arthroplasty (TKA) are well-described. Angiotensin receptor blockers (ARB), particularly losartan, is a commonly prescribed antihypertensive with demonstrated antifibrotic properties. This retrospective study aimed to assess the rates of 1- and 2-year postoperative complications in patients who filled prescriptions for ARBs during the 90 days after TKA. Patients undergoing primary TKA were selected from a large national insurance database, and the impact of ARB use after TKA on complications was assessed. Of the 1,299,106 patients who underwent TKA, 82,065 had filled at least a 90-day prescription of losartan, valsartan, or olmesartan immediately following their TKA. The rates of manipulation under anesthesia (MUA), arthroscopic lysis of adhesions (LOA), aseptic loosening, periprosthetic fracture, and revision at 1 and 2 years following TKA were analyzed using multivariable logistic regressions to control for various comorbidities. ARB use was associated with decreased rates of MUA (odds ratio [OR] = 0.94, 95% confidence interval (CI), 0.90 to 0.99), arthroscopy/LOA (OR = 0.86, 95% CI, 0.77 to 0.95), aseptic loosening (OR = 0.71, 95% CI, 0.61 to 0.83), periprosthetic fracture (OR = 0.58, 95% CI, 0.46 to 0.71), and revision (OR = 0.79, 95% CI, 0.74 to 0.85) 2 years after TKA. ARB use throughout the 90 days after TKA is associated with a decreased risk of MUA, arthroscopy/LOA, aseptic loosening, periprosthetic fracture, and revision, demonstrating the potential protective abilities of ARBs. Prospective studies evaluating the use of ARBs in patients at risk for postoperative stiffness would be beneficial to further elucidate this association. [ABSTRACT FROM AUTHOR]

• Drawbacks of current metrics compel use of novel patient-reported outcome indices. • This study developed MCID values for PROMIS, a novel patient-reported outcome metric. • Greater deformity severity by TS-CL was associated with lower MCID thresholds. Patient Reported Outcome Measurement Information System (PROMIS) instruments have been shown to correlate with established patient outcome metrics. The aim of this retrospective study was to determine the MCID for the PROMIS physical domains of Physical Function (PF), Pain Intensity (PI), and Pain Interference (Int) in a population of surgical cervical deformity (CD) patients. Surgical CD patients ≥ 18 years old with baseline (BL) and 3-month (3 M) HRQL data were isolated. Changes in HRQLs: ΔBL-3M. An anchor-based methodology was used. The cohort was divided into four groups: 'worse' (ΔEQ5D ≤ −0.12), 'unchanged' (≥0.12, but < −0.12), 'slightly improve' (>0.12, but ≤ 0.24), and 'markedly improved' (>0.24) [0.24 is the MCID for EQ5D]. PROMIS-PF, PI and Int at 3M was compared between 'slightly improved' and 'unchanged'. ROC computed discrete MCID values using the change in PROMIS that yielded the smallest difference between sensitivity ('slightly improved') and specificity ('unchanged'). We repeated anchor-based methods for the Ames-ISSG classification of severe deformity. 140 patients were included. EQ5D groups: 9 patients 'worse', 53 'unchanged', 20 'slightly improved', and 57 'markedly improved'. Patients classified as 'unchanged' exhibited a PROMIS-PF improvement of 2.9 ± 17.0 and those 'slightly improved' had an average gain of 13.3 ± 17.8. ROC analysis for the PROMIS-PF demonstrated an MCID of +2.26, for PROMIS-PI of −5.5, and PROMIS-Int of −5.4. In the Ames-ISSG TS-CL severe CD modifier, ROC analysis found MCIDs of PROMIS physical domains: PF of +0.5, PI of −5.2, and Int of −5.4. MCID for PROMIS physical domains were established for a cervical deformity population. MCID in PROMIS Physical Function was significantly lower for patients with severe cervical deformity. [ABSTRACT FROM AUTHOR]

• Examined the predictors of myocardial infarction (MI) following elective spine procedures. • 436 patients had an acute MI out of 196,523 elective spine surgery patients. • MI predictors included diabetes, cardiac arrest and PVD, blood transfusion, dialysis-dependence, low preop platelet count, SSI and days from operation to discharge. • This can aid in the risk stratification of preoperative patients prior to spinal operations. Myocardial infarction (MI), and its predictive factors, has been an understudied complication following spine operations. The objective was to assess the risk factors for perioperative MI in elective spine surgery patients as a retrospective case control study. Elective spine surgery patients with a perioperative MI were isolated in the NSQIP. The relationship between MI and non-MI spine patients was assessed using chi-squared and independent samples t-tests. Univariate/multivariate analyses assessed predictive factors of MI. Logistic regression with stepwise model selection was employed to create a model to predict MI occurrence. The study included 196,523 elective spine surgery patients (57.1 yrs, 48%F, 30.4 kg/m2), and 436 patients with acute MI (Spine-MI). Incidence of MI did not change from 2010 to 2016 (0.2%–0.3%, p = 0.298). Spine-MI patients underwent more fusions than patients without MI (73.6% vs 58.4%, p < 0.001), with an average of 1.03 levels fused. Spine-MI patients also had significantly more SPO (5.0% vs 1.8%, p < 0.001) and 3CO (0.9% vs 0.2%, p < 0.001), but less decompression-only procedures (26.4% vs 41.6%, p < 0.001). Spine-MI underwent more revisions (5.3% vs 2.9%, p = 0.003), had greater invasiveness scores (3.41 vs 2.73, p < 0.001) and longer operative times (211.6 vs 147.3 min, p < 0.001). Mortality rate for Spine-MI patients was 4.6% versus 0.05% (p < 0.001). Multivariate modeling for Spine-MI predictors yielded an AUC of 83.7%, and included history of diabetes, cardiac arrest and PVD, past blood transfusion, dialysis-dependence, low preoperative platelet count, superficial SSI and days from operation to discharge. A model with good predictive capacity for MI after spine surgery now exists and can aid in risk-stratification of patients, consequently improving preoperative patient counseling and optimization in the peri-operative period. [ABSTRACT FROM AUTHOR]

• After weight-loss surgery, patients no longer sought care for their spinal diagnosis • Lumbar herniation had higher resolution than cervical herniation by 90 days. • Cervical degeneration and stenosis resolved at higher rates than lumbar pathologies. The effects of bariatric surgery on diminishing spinal diagnoses have yet to be elucidated in the literature. The purpose of this study was to assess the rate in which various spinal diagnoses diminish after bariatric surgery. This was a retrospective analysis of the NYSID years 2004–2013. Patient linkage codes allow identification of multiple and return inpatient stays within the time-frame analyzed (720 days). Time from bariatric surgery until the patient's respective spinal diagnosis was no longer present was considered a loss of previous spinal diagnosis (LOD). Included: 4,351 bariatric surgery pts with a pre-op spinal diagnosis. Cumulative LOD rates at 90-day, 180-day, 360-day, and 720-day f/u were as follows: lumbar stenosis (48%,67.6%,79%,91%), lumbar herniation (61%,77%,86%,93%), lumbar spondylosis (47%,65%,80%,93%), lumbar spondylolisthesis (37%,58%,70%,87%), lumbar degeneration (37%,56%,72%,86%). By cervical region: cervical stenosis (48%,70%,84%,94%), cervical herniation (39%,58%,74%,87%), cervical spondylosis (46%, 70%,83%, 94%), cervical degeneration (44%,64%,78%,89%). Lumbar herniation pts saw significantly higher 90d-LOD than cervical herniation pts (p < 0.001). Cervical vs lumbar degeneration LOD rates did not differ @90d (p = 0.058), but did @180d (p = 0.034). Cervical and lumbar stenosis LOD was similar @90d & 180d, but cervical showed greater LOD by 1Y (p = 0.036). In conclusion, over 50% of bariatric patients diagnosed with a cervical or lumbar pathology before weight-loss surgery no longer sought inpatient care for their respective spinal diagnosis by 180 days post-op. Lumbar herniation had significantly higher LOD than cervical herniation by 90d, whereas cervical degeneration and stenosis resolved at higher rates than corresponding lumbar pathologies by 180d and 1Y f/u, respectively. [ABSTRACT FROM AUTHOR]

• Improvements in radiographic Ames modifier grades correlate with better clinical outcomes and spinal alignment. • Deformity descriptors have differential responses to modifier improvements. • The Ames-ACD classification may apply to cervical deformity patients' postoperative alignment and outcomes. This retrospective cohort study describes adult cervical deformity(ACD) patients with Ames-ACD classification at baseline(BL) and 1-year post-operatively and assesses the relationship of improvement in Ames modifiers with clinical outcomes. Patients ≥ 18yrs with BL and post-op(1-year) radiographs were included. Patients were categorized with Ames classification by primary deformity descriptors (C = cervical; CT = cervicothoracic junction; T = thoracic; S = coronal) and alignment/myelopathy modifiers(C2-C7 Sagittal Vertical Axis[cSVA], T1 Slope-Cervical Lordosis[TS-CL], Horizontal Gaze[Horiz], mJOA). Univariate analysis evaluated demographics, clinical intervention, and Ames deformity descriptor. Patients were evaluated for radiographic improvement by Ames classification and reaching Minimal Clinically Important Differences(MCID) for mJOA, Neck Disability Index(NDI), and EuroQuol-5D(EQ5D). A total of 73 patients were categorized: C = 41(56.2%), CT = 18(24.7%), T = 9(12.3%), S = 5(6.8%). By Ames modifier 1-year improvement, 13(17.8%) improved in mJOA, 26(35.6%) in cSVA grade, 19(26.0%) in Horiz, and 15(20.5%) in TS-CL. The overall proportion of patients without severe Ames modifier grades at 1-year was as follows: 100% cSVA, 27.4% TS-CL, 67.1% Horiz, 69.9% mJOA. 1-year post-operatively, severe myelopathy(mJOA = 3) prevalence differed between Ames-ACD descriptors (C = 26.3%, CT = 15.4%, T = 0.0%, S = 0.0%, p = 0.033). Improvement in mJOA modifier correlated with reaching 1-year NDI MCID in the overall cohort (r = 0.354,p = 0.002). For C descriptors, cSVA improvement correlated with reaching 1-year NDI MCID (r = 0.387,p = 0.016). Improvement in more than one radiographic Ames modifier correlated with reaching 1-year mJOA MCID (r = 0.344,p = 0.003) and with reaching more than one MCID for mJOA, NDI, and EQ-5D (r = 0.272,p = 0.020). In conclusion, improvements in radiographic Ames modifier grades correlated with improvement in 1-year postoperative clinical outcomes. Although limited in scope, this analysis suggests the Ames-ACD classification may describe cervical deformity patients' alignment and outcomes at 1-year. [ABSTRACT FROM AUTHOR]

• Psychiatric diagnoses have an impact on the treatment and outcomes of patients undergoing elective orthopedic procedures. • Afflicted patients are more likely to have higher costs surgeries, extended length of stays, and death during their admission. Psychiatric diagnoses (PD) present a significant burden on elective surgery patients and may have potentially dramatic impacts on outcomes. As ailments of the spine can be particularly debilitating, the effect of PD on outcomes was compared between elective spine surgery patients and other common elective orthopedic surgery procedures. This study included 412,777 elective orthopedic patients who were concurrently diagnosed with PD within the years 2005 to 2016. 30.2% of PD patients experienced a post-operative complication, compared to 25.1% for non-PD patients (p < 0.001). Mood Disorders (bipolar or depressive disorders) were the most commonly diagnosed PD for all elective Orthopedic procedures, followed by anxiety, then dementia (p < 0.001). Logistic regression analysis found PD to be a significant predictor of higher cost to charge ratio (CCR), length of stay (LOS), and death (all p < 0.001). Between, hand, elbow, and shoulder specialties, spine patients had the highest odds of increased CCR and unfavorable discharge, and the second highest odds of death (all p < 0.001). [ABSTRACT FROM AUTHOR]

• Cost utility analysis of surgical treatment for ASD in different frailty states. • F and SF patients had lower Cost/QALY compared to non-frail patients at 2 years and life expectancy. • ASD surgery is a cost-effective treatment option in both NF and F/SF groups. The aim of this study was to investigate the cost utility of treating non-frail versus frail or severely frail adult spinal deformity (ASD) patients. 79 surgical ASD patients >18 years with available frailty and ODI data at baseline and 2-years post-surgery (2Y) were included. Utility data was calculated using the ODI converted to the SF-6D. QALYs utilized a 3% discount rate to account for decline to life expectancy (LE). Costs were calculated using the PearlDiver database. ICER was compared between non-operative (non-op.) and operative (op.) NF and F/SF patients at 2Y and LE. When compared to non-operative ASD, the ICER was $447,943.96 vs. $313,211.01 for NF and F/SF at 2Y, and $68,311.35 vs. $47,764.61 for NF and F/SF at LE. Frail and severely frail patients had lower cost per QALY compared to not frail patients at 2Y and life expectancy, and had lower ICER values when compared to a non-operative cohort of ASD patients. While these results support operative correction of frail and severely frail patients, it is important to note that these patients are often at worse baseline disability, which is closely related to frailty scores, and have more opportunity to improve postoperatively. Furthermore, there may be a threshold of frailty that is not operable due to the risk of severe complications that is not captured by this analysis. While future research should investigate economic outcomes at extended follow up times, these findings support the cost effectiveness of ASD surgery at all frailty states. [ABSTRACT FROM AUTHOR]

• Surgical spine patients with shorter LOS had increased rates of complications and readmissions. • Patients with Clavien Grade 5 complications in 2015 had the lowest mean time to readmission. • Negative outcomes may be diminished with careful patient selection. There has been limited discussion as to whether spine surgery patients are benefiting from shorter in-patient hospital stays or if they are incurring higher rates of readmission and complications secondary to shortened length of stays. Included in this study were 237,446 spine patients >18yrs and excluding infection. Patients with Clavien Grade 5 complications in 2015 had the lowest mean time to readmission after initial surgery in all years at 12.44 ± 9.03 days. Pearson bivariate correlations between LOS ≤ 1 day and decreasing days to readmission was the strongest in 2016.). Logistic regression analysis found that LOS ≤ 1 day showed an overall increase in the odds of hospital readmission from 2012 to 2016 (2.29 [2.00–2.63], 2.33 [2.08–2.61], 2.35 [2.11–2.61], 2.27 [2.06–2.49], 2.33 [2.14–2.54], all p < 0.001). [ABSTRACT FROM AUTHOR]

• Elective spine surgery patients experienced an overall HAC rate of 3.3% • HACs are more common in elective spine surgery as compared to other common elective procedures. • Common HACs in spine surgery are surgical site infection, UTI, and venous thromboembolism. Hospital-acquired conditions (HACs) have been the focus of recent initiatives by the Centers for Medicare and Medicaid Services in an effort to improve patient safety and outcomes. Spine surgery can be complex and may carry significant comorbidity burden, including so called "never events." The objective was to determine the rates of common HACs that occur within 30-days post-operatively for elective spine surgeries and compare them to other common surgical procedures. Patients: >18 y/o undergoing elective spine surgery were identified in the American College of Surgeons' NSQIP database from 2005 to 2013. Patients were stratified by whether they experienced >1 HAC, then compared to those undergoing other procedures including bariatric surgery, THA and TKA. Of the 90,551 spine surgery patients, 3021 (3.3%) developed at least one HAC. SSI was the most common (1.4%), followed by UTI (1.3%), and VTE (0.8%). Rates of HACs in spine surgery were significantly higher than other elective procedures including bariatric surgery (2.8%) and THA (2.8%) (both p < 0.001). Spine surgery and TKA patients had similar rates of HACs(3.3% vs 3.4%, p = 0.287), though spine patients experienced higher rates of SSI (1.4%vs0.8%, p < 0.001) and UTI (1.3%vs1.1%, p < 0.001) but lower rates of VTE (0.8%vs1.6%, p < 0.001). Spine surgery patients had lower rates of HACs overall (3.3%vs5.9%) when compared to cardiothoracic surgery patients (p < 0.001). When compared to other surgery types, spine procedures were associated with higher HACs than bariatric surgery patients and knee and hip arthroplasties overall but lower HAC rates than patients undergoing cardiothoracic surgery. [ABSTRACT FROM AUTHOR]

• Operative intervention was associated with lower 30-day mortality and 1-year mortality compared to conservative treatment. • Increased mFI was associated with higher short-term mortality. • mFI > 3 trended higher mortality regardless of intervention. Investigate outcomes in a spondylodiscitis (SD) patient cohort undergoing operative and medical treatment or medical treatment alone, accounting for frailty status at presentation. Patients >18 years old undergoing treatment for SD were retrospectively analyzed. The diagnosis of SD was made through a combination of clinical findings, MRI/CT findings, and blood/tissue cultures. Those who failed to respond to antibiotics, had deteriorating markers, or developed neurologic compromise were considered operative candidates. Patients were stratified based on operative (Op, operative plus medical management) or conservative (Cons, medical only) treatment. Univariate analyses identified differences in outcome measures across treatment groups. Conditional forward regression equations, controlling for patient age, identified predictors of increased mortality and inferior outcomes. 116 patients with SD were included. 73 underwent Cons treatment and 43 were Op. Op patients were significantly younger (62.9vs70.7yrs; p < 0.001) and less frail (1.09vs1.85; p < 0.006) than Cons patients, with significantly higher WCC and ESR. Cons pts had higher rates of isolated SD, but Op pts had higher rates of SD with associated SEA, VOM, psoas abscess, and para-vertebral abscess (all p < 0.05). Op pts had significantly lower 30-day mortality than Cons pts (2.3%vs17.8%, p = 0.016), and trended lower 1Y mortality (11.6%vs20.5%, p = 0.310) with similar SD recurrence rates (11.6%vs16.4%, p = 0.592). Patients with an mFI > 3 had significantly higher 30-day mortality (30.4% vs 7.5%, p = 0.003) and trended higher 1-year mortality regardless of intervention. Operative intervention was associated with lower 30-day mortality significantly and 1-year mortality compared to conservative treatment, while an increased mFI was associated with higher short-term mortality. [ABSTRACT FROM AUTHOR]

• Lordotic curvature correlated with C2-C7 fatty infiltration. • Residual postop TS-CL and cSVA malalignment associated with greater apex fatty-infiltration. • Deformity correction and sagittal balance influence cervical muscle tone. To assess preliminary associations between fatty-infiltration (FI) of cervical spine extensor musculature, cervical sagittal balance, and clinical outcomes in cervical deformity (CD) patients. Operative CD patients (C2-C7 Cobb > 10°, CL > 10°, cSVA > 4 cm, or CBVA > 25°) with pre-operative (BL) MRIs and 1-year (1Y) post-operative MRIs or CTs were assessed for fatty-infiltration of cervical extensor musculature, using dedicated imaging software at each C2-C7 intervertebral level and the apex of deformity (apex). FI was gauged as a ratio of fat-free-muscle-cross-sectional-area (FCSA) over total-muscle-CSA (TCSA), with lower ratio values indicating greater FI. BL-1Y associations between FI, sagittal alignment, and clinical outcomes were assessed using appropriate parametric and non-parametric tests. 22 patients were included (Age 59.22, 71.4%F, BMI 29.2, CCI:0.75, Frailty: 0.43). BL deformity presentation: TS-CL: 29.0°, C2-C7 Sagittal Cobb:-1.6°, cSVA:30.4 mm. No correlations were observed between BL fatty-infiltration, sagittal alignment, frailty, or clinical outcomes (p > 0.05). Following surgical correction, C2-C7 (BL: 0.59 vs 1Y:0.67, p = 0.005) and apex (BL: 0.59 vs. 1Y: 0.66, p = 0.33) fatty-infiltration decreased. Achievement of lordotic curvature correlated with C2-C7 fatty infiltration reduction (R s : 0.495, p < 0.05), and patients with residual postoperative TS-CL and cSVA malalignment were associated with greater apex fatty-infiltration (R s : −0.565, −0.561; p < 0.05). C2-C7 FI improvement was associated with NRS back pain reduction (R s : −0.630, p < 0.05), and greater apex fatty-infiltration at BL was associated with minor perioperative complication occurrence (R s : 0.551, p = 0.014). Deformity correction and sagittal balance appear to influence the reestablishment of cervical muscle tone from C2-C7 and reduction of back pain for severely frail CD patients. This analysis helps to understand cervical extensor musculature's role amongst CD patients. [ABSTRACT FROM AUTHOR]

With the increasing prevalence of hip-spine syndrome, it is crucial to appreciate the biomechanical interplay between hip and spine degeneration or deformity and the consequential compensatory changes. Adult spinal deformity (ASD) patients are uniquely affected as a concomitant hip osteoarthritis (HOA) may impact their baseline and postoperative sagittal alignment. Similarly, severe HOA patients undergoing total hip replacement with concomitant spinal deformity may require personalized surgical planning for the placement of their acetabular component. If surgical intervention is required in ASD patients, the authors' preferred sequence is to perform spinal realignment first. If major realignment is not planned, we recommend treating the most symptomatic pathology. Further investigation is required to evaluate the impact of hip pathology on radiographic and patient-reported outcomes following ASD surgery and vice versa. [ABSTRACT FROM AUTHOR]

Concepts regarding sagittal plane alignment in adult spinal deformity (ASD) surgery are evolving in the pursuit of individualized care with personalized targets. We have moved past simple targets of mismatch between lumbar lordosis and pelvic incidence, as these ignore the distribution, and the subsequent shape, of lumbar lordosis. Several classification systems and alignment strategies exist, with some proposing alignment to "normal" while others seek age-appropriate spinal alignment. While differences exist, the importance of the pelvic incidence as a fixed parameter from which one may build the spine is common to all theories. The purpose of this narrative review is to summarize the literature regarding the current concepts behind spinal alignment theories and the data supporting these theories. [ABSTRACT FROM AUTHOR]

Integrating functional evaluation of adult spinal deformity (ASD) patients is an integral component of clinical evaluation. While the spine community has acknowledged its significance, functional assessment is often absent in academic research due to standardization challenges. This review aims to outline diverse modalities for ASD functional assessment, ranging from simple to complex methods available only in dedicated laboratories. Addressing this gap will enhance our understanding of ASD's functional impact and guides improved research and patient care. [ABSTRACT FROM AUTHOR]

• Examined extended length of hospital stay in myelopathy, radiculopathy and myeloradiculopathy patients. • 102 patients had extended length of stay, average: 5.96 days. • Predictors of extended length of stay were explored for each diagnosis. • Independent of invasiveness, patients with a diagnosis of myelopathy, had longer LOS. In the current value-based healthcare climate where spine surgery is shifting to the ambulatory setting, factors influencing postop length of stay (LOS) are important to surgeons and hospital administrators. Pre-op patient factors including diagnosis of radiculopathy and myelopathy have yet to be investigated in this context. Operative pts ≥ 18Y with primary diagnoses of cervical myelopathy (M), radiculopathy (R), or myeloradiculopathy (MR) were included and propensity score matched by invasiveness score (Mirza et al.). Top-quartile LOS was defined as extended. M&R patients were compared using Chi2 & independent t -tests. Univariate tests assessed differences in preop patient and surgical data in M&R pts and extended/non-extended LOS. Stepwise regression analysis explored factors predictive of LOS. 718 operative pts (54.5 yrs, 41.1%F, 29.1 kg/m2, mean CCI 1.11) included (177 M, 383 R, and 158 MR). After PSM, 345 patients remained (115 in each diagnosis). 102 patients had E-LOS (Avg: 5.96 days), 41 M patients (mean 7.1 days), 28 R (5.9 days), and 33 MR (4.6 days). Regression showed predictors of E-LOS in R pts (R2 = 0.532, p = 0.043): TS-CL, combined and posterior approach, LIV, UIV, op time, Lactated Ringer's, postoperative complications. Predictors of E-LOS in M pts (R2 = 0.230, p < 0.001): age, CCI, combined and posterior approach, levels fused, UIV, EBL, neuro and any postop complications. Predictors of E-LOS in MR patients (R2 = 0.152, p < 0.001): age, kyphosis, combined approach, UIV, LIV, levels fused, EBL and op time. Independent of invasiveness, patients with a primary diagnosis of myelopathy, though older aged and higher comorbidity profile, had consistently longer overall postop LOS when compared to radiculopathy or myeloradiculopathy patients. [ABSTRACT FROM AUTHOR]

Highlights • EOS patients with musculoskeletal conditions more likely to have renal anomalies. • Epilepsy and pulmonary failure were risks for patients with pulmonary disease. • Clustered neurologic and pulmonary anomalies increased mortality risk. • Clustered musculoskeletal and cardiovascular anomalies increased length of stay. Abstract This study sought to assess comorbidity profiles unique to early-onset-scoliosis (EOS) patients by employing cluster analytics and to determine the influence of isolated comorbidity clusters on perioperative complications, morbidity and mortality using a high powered administrative database. The KID database was queried for ICD-9 codes pertaining to congenital and idiopathic scoliosis from 2003, 2006, 2009, 2012. Patients <10 y/o (EOS group) were included. Demographics, incidence and comorbidity profiles were assessed. Comorbidity profiles were stratified by body systems (neurological, musculoskeletal, pulmonary, cardiovascular, renal). K-means cluster and descriptive analyses elucidated incidence and comorbidity relationships between frequently co-occurring comorbidities. Binary logistic regression models determined predictors of perioperative complication development, mortality, and extended length-of-stay (≥75th percentile). 25,747 patients were included (Age: 4.34, Female: 52.1%, CCI: 0.64). Incidence was 8.9 per 100,000 annual discharges. 55.2% presented with pulmonary comorbidities, 48.7% musculoskeletal, 43.8% neurological, 18.6% cardiovascular, and 11.9% renal; 38% had concurrent neurological and pulmonary. Top inter-bodysystem clusters: Pulmonary disease (17.2%) with epilepsy (17.8%), pulmonary failure (12.2%), restrictive lung disease (10.5%), or microcephaly and quadriplegia (2.1%). Musculoskeletal comorbidities (48.7%) with renal and cardiovascular comorbidities (8.2%, OR: 7.9 [6.6–9.4], p < 0.001). Top intra-bodysystem clusters: Epilepsy (11.7%) with quadriplegia (25.8%) or microcephaly (20.5%). Regression analysis determined neurological and pulmonary clusters to have a higher odds of perioperative complication development (OR: 1.28 [1.19–1.37], p < 0.001) and mortality (OR: 2.05 [1.65–2.54], p < 0.001). Musculoskeletal with cardiovascular and renal anomalies had higher odds of mortality (OR: 1.72 [1.28–2.29], p < 0.001) and extLOS (OR: 2.83 [2.48–3.22], p < 0.001). EOS patients with musculoskeletal conditions were 7.9x more likely to have concurrent cardiovascular and renal anomalies. Clustered neurologic and pulmonary anomalies increased mortality risk by as much as 105%. These relationships may benefit pre-operative risk assessment for concurrent anomalies and adverse outcomes. Level of Evidence : III – Retrospective Prognostic Study. [ABSTRACT FROM AUTHOR]

Highlights • Utilized the Clavien system to classify complications post ASD-corrective surgery. • 32.1% of patients suffered at least one Clavien complication. • CCI and complications decreased, frailty and invasiveness increased temporally. • Rates of Grade II and IV decreased, indicative of surgical improvements. Abstract The Clavien-Dindo grading allows for broad comparison of perioperative surgical complications, and a temporal analysis of complications following ASD-corrective surgery. NSQIP database was utilized from 2010 to 2014 to isolate patients. Complications were stratified by Clavien complication (Cc) grade, and patients grouped by highest Cc grade: I, II, III, IV, V. Secondary analysis grouped by minor (I, II, III) and severe (IV, V). Comorbidity burden was assessed with a NSQIP-modified Charlson Comorbidity Index (CCI) and frailty was measured with a 5-factor modified frailty index (mFI). From 2010 to 2014, 2971 patients (57 yrs, 58% F) underwent surgery for ASD (3.4 ± 4.1 levels; surgical approach: 46% anterior, 44% posterior, 10% combined), the rate of which increased 0.01% to 0.13. 32% suffered >1 complication. Patient breakdown by Cc grade: 0% I, 25% II, 3% III, 4% IV, 1% V. Severe Cc patients were more comorbid than minor Cc (CCI 2.8 vs 1.8), had longer operative times (394 min vs 251), and higher rates of osteotomy (29% vs 13%) and iliac fixation (16% vs 5%). Overall CCI (2.1–1.7) and perioperative complication rates (55–29%) decreased, despite increasing surgical invasiveness (2.8–4.5) and increasing frailty score (0.14 ± 0.15 vs 0.16 ± 0.16). Rates of Clavien grade II (39.80–22.20%) and IV (9.40–3.50%) complications also decreased, indicative of surgical improvements and effective preoperative patient selection. The decrease in CCI and increase in the modified frailty score may show that we are becoming more cognizant of discerning of comorbidities, but likely to not to have taken into account frailty, which may have an impact on future health socioeconomics. [ABSTRACT FROM AUTHOR]

Highlights • Multi-segment posterior decompression and fusion patients had worse post-operative alignment without pre-operative planning. • Patients with pre-contoured rods and pre-operative planning demonstrated a greater correction of TS-CL after surgery than un-planned cases, though this was limited by the pre-operative difference in cervical-thoracic mismatch between planned and unplanned cases. • Worsening of TS-CL without surgical planning and patient-specific rods for minor cervical deformity patients highlights the attention needed by surgeons for these minor deformities to ensure that cervical alignment does not deteriorate post-operatively. Abstract Patient-specific rods designed based on a particular pre-operative plan are a recent advancement to help achieve desired operative alignment goals. This study investigated the role of pre-operative planning and patient-specific rods on post-operative alignment and outcomes. Patients were grouped according to use of pre-operative planning and patient-specific, pre-contoured rods (PLAN) or absence of planning/rods (NON). Pre-operative and post-operative alignment were measured: cervical sagittal vertical axis (cSVA), cervical lordosis (CL), T1 Slope minus CL (TS-CL). Alignment differences between the groups were assessed using independent and paired samples t -tests. 34 patients were identified (15 PLAN, 19 NON). Pre- and post-operative CL, cSVA and TS were similar between the two groups (p > 0.05), though pre-operative TS-CL was slightly higher in PLAN patients (28.13° versus 18.42°, p = 0.049). There were no improvement differences pre- to post-operative for CL, cSVA and TS between the groups (p > 0.05). However, PLAN patients exhibited a greater correction of TS-CL, with an average of 5.8° decrease versus a 3.5° increase in TS-CL for NON patients (p = 0.015). PLAN patients did not demonstrate a significant change from pre- to post-operative alignment for cSVA or TS-CL (cSVA: 27.5 mm to 31.1 mm, p = 0.255; TS-CL: 28.1° to 22.3°, p = 0.13), though their TS-CL did trend towards significant post-operative improvement. In contrast, NON patients worsened in cSVA and TS-CL post-operatively (cSVA: 21.8 mm to 30.3 mm, p < 0.001; TS-CL: 18.4° to 22.0°, p = 0.035). Multi-segment posterior decompression and fusion patients have the potential to worsen with regards to post-operative alignment without pre-operative planning. Patients with pre-contoured rods and pre-operative planning exhibited a greater correction of TS-CL after surgery than un-planned cases, though limited by the pre-operative difference in cervical-thoracic mismatch between planned and unplanned cases. Levels of evidence III. [ABSTRACT FROM AUTHOR]

Highlights • 21.1% of our cohort of operative CD patients had radiographic pre-operative PJK. • Patients with CD secondary to PJK had worse baseline CD. • Surgical correction of CD associated with PJK was more invasive and complicated. Abstract CD development secondary to PJK was recently documented in adult spinal deformity patients after surgical correction for thoracolumbar ASD. This study analyzes surgical management of patients with CD secondary to proximal junctional kyphosis (PJK) versus patients with primary CD. Retrospective review of multicenter cervical deformity (CD) database. CD defined as at least one of the following: C2–C7 coronal Cobb > 10°, cervical lordosis (CL) > 10°, cervical sagittal vertical axis (cSVA) > 4cm, CBVA > 25°. Patients were grouped into those with PJK (UIV +2 < −10°) prior to cervical surgery versus who don't (Non-PJK). Independent t-tests and chi-squared tests compared radiographic, clinical, and surgical metrics between PJK and non-PJK groups. Of 123 eligible CD patients, 26(21.1%) had radiographic PJK prior to cervical surgery. PJK patients had significantly greater T2–T12 thoracic kyphosis (−58.8° vs −45.0°, p = 0.002), cSVA (49.1 mm vs 38.9 mm, p = 0.020), T1 Slope (42.6° vs 28.4°, p < 0.001), TS-CL (44.1° vs 35.6°, p = 0.048), C2-T3 SVA (98.8 mm vs 75.8 mm, p = 0.015), C2 Slope (45.4° vs 36.0°, p = 0.043), and CTPA (6.4° vs 4.6°, p = 0.005). Comparing their surgeries, the PJK group had significantly more levels fused (10.7 vs 7.4, p = 0.01). There was significantly greater blood loss in PJK patients (1158 ± 1063vs 738 ± 793 cc, p = 0.028); operative time, surgical approach, and BMP-2 use were similar (all p > 0.05). PJK patients experienced higher rates of complications 30 and 90 days post-operatively (23.1% vs. 5.2%, p = 0.004; 30.8% vs. 19.6%, p = 0.026), and more instrumentation failure 30 days postoperatively (7.8% vs. 1.0%, p = 0.004). Patients with cervical deformity secondary to PJK had worse baseline CD, despite no differences in HRQL or demographics. Surgical correction of CD associated with PJK required more invasive surgery and had higher complication rates than non-PJK patients, despite achieving similar clinical outcomes. [ABSTRACT FROM AUTHOR]

Optimizing functional outcomes and disability status are essential for effective surgical treatment of cervical spine disorders. Mental impairment is common among patients with cervical spine complaints; yet little is known about the impact of baseline mental status with respect to overall patient-reported outcomes. This was a retrospective analysis of patients with cervical spondylosis with myelopathy(CM) or radiculopathy(CR: cervical disc herniation, stenosis, or spondylosis without myelopathy) at 2-year follow-ups. Patients were assessed for several health-related quality of life HRQOL) measures at baseline and 24-months post-operatively: Neck Disability Index (NDI), Visual Analog Scale(VAS), Short Form-36(SF) Physical(PCS) and Mental(MCS) Components. Patients were dichotomized by MCS score: LOW-MCS(SF-MCS < 40th percentile) vs. HIGH-MCS(SF-MCS > 60th percentile). Independent and paired t -tests compared improvement in each group for HIGH-MCS and LOW-MCS cohorts. 375 patients were analyzed(65.4yrs, 67.6%F). LOW-MCS radiculopathy patients showed significant improvement in NDI, VAS Neck and Arm Pain(p < 0.05). HIGH-MCS radiculopathy patients showed greater improvement in NDI score, VAS Neck and Arm Pain, and improvement in PCS(all p < 0.05). Comparing baseline and 2-year follow-up, LOW-MCS CM patients showed significant improvement in PCS, NDI, VAS Neck and Arm Pain(p < 0.05). HIGH-MCS myelopathy patients group showed marked improvement in NDI scores, VAS Neck and Arm Pain(p < 0.05). LOW-MCS CR patients were more likely to be less satisfied 2-years post-op(p < 0.001). Postoperative CR patients with lower baseline mental status saw less improvement and significantly worse outcomes than patients with higher baseline mental status. Improving baseline mental health may improve post-operative recovery. Implementing additional screening and care can optimize functional outcomes and disability status for patients with CR. [ABSTRACT FROM AUTHOR]

Surgical treatment for spinal metastasis has benefited from improvements in surgical techniques. However, the trends in treatment and outcomes for spinal metastasis surgery have not been well-established in a pediatric population. Patients <20 years old with metastatic spinal tumors undergoing spinal surgery were identified in the KID database. Trends for spinal metastases treatment and patient outcomes were analyzed using weight-adjusted ANOVAs. 333 patients were identified in the KID database. The top five primary diagnoses were metastatic brain/spinal cord tumor (19.8%), metastatic nervous system tumor (15.9%), metastatic bone cancer (13.2%), spinal cord tumor (4.2%), and tumor of ventricles (3.0%). There was an increased incidence of spinal metastasis diagnoses from 2003 to 2012 (88.5–117.9 per 100,000; p < 0.001) and an increased trend in the incidence of surgical treatment for spinal metastasis from 2003 to 2012 (p = 0.014). The average age was 10.19 ± 6.33 years old and 38.4% were female. The average length of stay was 17.34 ± 24.36 days. Average CCI increased over time (2003: 7.87 ± 1.40, 2012: 8.44 ± 1.39; p = 0.006). The most common surgeries were excision of spinal cord/meninges lesions (69.1%) and decompression of spinal canal (38.1%). Length of hospital stay and in-hospital mortality did not change over time (17.34–18.04 days, p = 0.337; 1.6%–2.9%, p = 0.801). 10.5% of patients underwent a posterior fusion and 22.2% had at least one complication (nervous system, respiratory, dysphagia, infection). The overall complication rate remained stable over time (23.4%–21.8%, p = 0.952). Surgical treatment for spinal metastasis in the last decade has increased, though the complication rates, in-hospital mortality, and length of stay have remained stable. [ABSTRACT FROM AUTHOR]

Prior studies assessed the association between underlying neurological condition and worse outcomes following spinal surgery with recent emphasis of self-reported loss of balance (Imbalance) by Uribe et al. To investigate if patients with self-reported loss of balance have poorer outcomes following adult spinal deformity (ASD) surgery. Retrospective review of prospectively collected database. ASD patients with baseline and 2-year radiographic and patient-reported outcome measure (PROM) data were included. Demographics, radiographic outcomes, complications, and PROM were compared from baseline to 2-year follow up. Patients undergoing a long spinal fusion with no prior history of spine surgery were retained. Patients were grouped according to imbalance and unsteady gait. The groups were propensity matched by age, PI-LL, and surgical invasiveness score. Demographics, radiographic, complications and PROM were compared from baseline to 2-year post-op. A total of 212 patients were reported (106 patients in each group). The mean age (64 vs 63 years), BMI (27.2 vs 27.0 kg/m2), and gender (76% vs 87% female) were not significantly different for patients with imbalance and without imbalance respectively (all p >0.05). Patients in the imbalance group had a higher Frailty Index Score compared to patients without imbalance (3.74 vs 2.33, p <0.001). At baseline, the sagittal profile for both groups were comparable with regard to PT, PI-LL, and SVA. Patients with loss of balance had a significantly lower thoracic Cobb angle (25.27° vs 37.45°, p <0.001) and lumbar Cobb angle (37.03° vs 45.53°, p=0.004), although the global coronal alignment was similar (imbalance:41.51 mm vs 34.25 mm, p=0.155). Patients with imbalance had worse PROM measures, including ODI (45.15 vs 36.62), SF-36 Mental Component Score (44.04 vs 51.76), SF-36 Physical Component Score (30.17 vs 35.10), and SRS-22 Mental domain score (3.28 vs 3.80) (p <0.001 for all). Postoperatively, patients with imbalance had less PT correction (-1.45° vs -3.60°, p=0.039) for a comparable correction in their PI-LL (-11.93° vs-15.08°, p=0.144) by 2-year follow-up. Both groups demonstrated similar improvements in their coronal plane deformity. Imbalance patients had higher rates of radiographic PJK at 2-year follow-up (26.4% vs 14.2%, p=0.026). Furthermore, patients with reported imbalance have significantly higher rate of implant related complications (47.2% vs 34.0%, p=0.05). After controlling for age, baseline sagittal parameters, PI-LL correction and Charlson Comorbidity Index, patients with imbalance had 2.2 times increased odds of sustaining PJK by 2 years. Patients with a self-reported loss of balance and unsteady gait have significantly worse baseline frailty and PROMs, represented by poorer mental health and physical function. Although those patients had higher rates of PJK and implant-related complications, surgical intervention significantly improved their quality of life. Despite the improvement, they remained with lower PROMs by 2-year follow-up. Therefore, in the clinic setting and with limited institutional access to Frailty scores, asking patients if they have loss of balance or unsteady gait is a simple yet powerful question which may trigger their preoperative risk stratification and optimization. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

The Dubousset Functional Test (DFT) is a novel functional assessment tool. It has been shown that patients with spinal pathology take significantly longer to complete the DFT than do control patients. There has been a recent focus in the literature on using functional assessment to predict patient outcomes. To investigate the relationship between patients' performance of the novel four-component functional test proposed by Dubousset, sagittal alignment and patient-reported outcome measures PROMs. Prospective, single center study. Patients presenting to a single institution for lumbar degenerative disease or spinal deformity. The correlation between time to complete DFT, radiographic measures of sagittal alignment and PROMs. This is a prospective, single-center study including primary patients who presented for evaluation of lumbar degenerative disease and spinal deformity. DFT is a test which assesses 4 domains: Up and Walking Test (UWT), Steps Test (ST), Down and Sitting Test (DST), Dual Tasking Test (DTT). The UWT asks the patient to sit-to-stand unassisted, walk 5 m, and sit unassisted. ST asks the patient to ascend 3 steps, turn, and descend 3 steps. DST asks the patient to sit from standing, and then stand from sitting, both unassisted. Finally, DTT asks the patient to walk 5 m and back while counting down from 50 by 2. Each test was timed, and performance was scored in seconds required to finish the test. Spinopelvic radiographs and PROMs (EQ5D, ODI, SF12) were collected. DFT performance was stratified by 40th (Fast) and 60th (Slow) percentile cutoffs. Radiographic sagittal parameters were compared between groups. Regression models were built to predict DFT domains performances using alignment parameters. A total of 55 patients were included (52y, 66%F, BMI 25.6). Patients in all DFT Slow domains had significantly worse ODI (all above 40), EQ5D (all below 0.5), and worse SF12_PCS (all below 32) except DTT Slow patients who had a comparable PCS to Fast. UWT Slow patients had significantly greater PI-LL (15 vs 2), lower LL (45 vs 60), and greater PT (22 vs 12); DTT Slow had greater PT (22 vs 11); DST Slow had greater PT (23 vs 12), and greater PI-LL (13 vs 1); ST and DTT slow patients had comparable radiographic parameters to ST and DTT Fast; however, they were older (59 vs 43 ys) (all p <0.05). Greater PT correlated with longer time to perform UWT and DST (r=0.451, r=0.488, respectively, p < 0.05). Greater PI-LL correlated with longer UWT (r=0.349) and loss of LL with longer ST (r=0.416), all p <0.05. Notably, loss of L4-S1 correlated with slower UWT (r=0.377, p <0.05). Regression models revealed that PT, PI-LL and SVA together predict UWT with r=0.472, DST with r=0.370, DTT with r=0.310, and ST with r=0.149. The Dubousset Functional Test correlates with sagittal radiographic parameters and PROMs. PT, SVA, and PI-LL were able to predict up to 25% of patients' performance on the functional testing. Although radiographic parameters are helpful in guiding ASD treatment, they should be supplemented with other forms of patients' assessment which may include functional testing. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Background Context Obesity's impact on standing sagittal alignment remains poorly understood, especially with respect to the role of the lower limbs. Given energetic expenditure in standing, a complete understanding of compensation in obese patients with sagittal malalignment remains relevant. Purpose This study compares obese and non-obese patients with progressive sagittal malalignment for differences in recruitment of pelvic and lower-limb mechanisms. Study Design/Setting Single-center retrospective review. Patient Sample A total of 554 patients (277 obese, 277 non-obese) were identified for analysis. Outcome Measures Upper body alignment parameters: sagittal vertical axis (SVA) and T1 spinopelvic inclination (T1SPi). Compensatory lower-limb mechanisms: pelvic translation (pelvic shift [PS]), knee (KA) and ankle (AA) flexion, hip extension (sacrofemoral angle [SFA]), and global sagittal angle (GSA). Methods Inclusion criteria were patients ≥18 years who underwent full-body stereographic x-rays. Included patients were categorized as non-obese (N-Ob: body mass index [BMI]<30 kg/m 2 ) or obese (Ob: BMI≥30 kg/m 2 ). To control for potential confounders, groups were propensity score matched by age, gender, and baseline pelvic incidence (PI), and subsequently categorized by increasing spinopelvic (pelvic incidence minus lumbar lordosis [PI−LL]) mismatch: <10°, 10°–20°, >20°. Independent t tests and linear regression models compared sagittal (SVA, T1SPi) and lower limb (PS, KA, AA, SFA, GSA) parameters between obesity cohorts. Results A total of 554 patients (277 Ob, 277 N-Ob) were included for analysis and were stratified to the following mismatch categories: <10°: n=367; 10°–20°: n=91; >20°: n=96. Obese patients had higher SVA, KA, PS, and GSA than N-Ob patients (p<.001 all). Low PI−LL mismatch Ob patients had greater SVA with lower SFA (142.22° vs. 156.66°, p=.032), higher KA (5.22° vs. 2.93°, p=.004), and higher PS (4.91 vs. −5.20 mm, p<.001) than N-Ob patients. With moderate PI−LL mismatch, Ob patients similarly demonstrated greater SVA, KA, and PS, combined with significantly lower PT (23.69° vs. 27.14°, p=.012). Obese patients of highest (>20°) PI−LL mismatch showed greatest forward malalignment (SVA, T1SPi) with significantly greater PS, and a concomitantly high GSA (12.86° vs. 9.67°, p=.005). Regression analysis for lower-limb compensation revealed that increasing BMI and PI−LL predicted KA ( r 2 =0.234) and GSA ( r 2 =0.563). Conclusions With progressive sagittal malalignment, obese patients differentially recruit lower extremity compensatory mechanisms, whereas non-obese patients preferentially recruit pelvic mechanisms. The ability to compensate for progressive sagittal malalignment with the pelvic retroversion is limited by obesity. [ABSTRACT FROM AUTHOR]

Background Context: Adult spinal deformity (ASD) patients may gain minimal clinically important difference (MCID) in one or more of the health-related quality-of-life instruments without surgical intervention. The present study identifies the baseline characteristics of this subset of nonoperative patients and proposes predictors of those most likely to benefit.Purpose: The study aims to determine the factors that affect likelihood of nonoperative patients to reach MCID.Study Design/setting: This is a retrospective review of a prospective, multicenter database.Patient Sample: The study includes nonoperative ASD patients.Outcome Measures: Health-related quality-of-life measures, including the Scoliosis Research Society (SRS)-22 questionnaire, were used.Methods: The study used a multicenter database of 215 nonoperative patients with ASD and with minimum 2-year follow-up. Using a multivariate analysis, two groups were compared to identify possible predictors: those who reached MCID in the SRS pain or activity (N=86) at 2 years and those who did not reach MCID (N=129). A subgroup multivariate analysis of patients with a deficit (potential improvement) in both SRS pain and activity (N=84) was performed. Data collection was supported by a grant from DePuy for the International Spine Study Group Foundation.Results: At baseline, the nonoperative patients who reached MCID had a significantly lower SRS pain score (3.0 vs. 3.6), smaller thoracolumbar Cobb (TL Cobb) angle (29.6° vs. 36.5°; 87 patients with SRS-Schwab classification of lumbar or double), lower sacral slope (33.1° vs. 36.4°), and less lumbar lordosis (46.5° vs. 52.8°) (all p<.05). The SRS pain and TL Cobb were significant predictors for reaching MCID. The pelvic incidence minus lumbar lordosis (PI-LL) was significant on univariate analysis but not on multivariate analysis (7.5° vs. 2.6°; p=.14). In the subset of severely disabled patients, worse vertebral obliquity was a predictor for not achieving MCID (p<.05).Conclusions: Nonoperative ASD patients who achieved MCID in SRS activity or pain had a lower baseline SRS pain score and less coronal deformity in the TL region. Greater baseline pain offers significant room for potential improvement, which may be important in identifying ASD patients who have the potential to reach MCID nonoperatively. Coronal deformities in the TL region and associated vertebral obliquity may negatively impact potential for improvement in nonoperative care. [ABSTRACT FROM AUTHOR]

Midthoracic spinal levels (T5 to T8) are rarely chosen as the posterior upper instrumented vertebra (UIV) in spinopelvic fusions for adult spinal deformity (ASD). To compare the rates of complications between spinopelvic fusions with a midthoracic UIV to those with an upper thoracic or lower thoracic UIV. Retrospective analysis of prospectively collected multicenter registry data. All ASD patients with ≥2 years of follow-up in a multicenter registry with a sacropelvic (S1, S2, ilium) lower instrumented vertebra were included. Rates of any complication, surgical complications, and reoperation We used multivariable regression to identify factors associated with selection for an upper-midthoracic UIV (UM UIV, T5 or T6), as opposed to an UT UIV, and selection for a lower-midthoracic UIV (LM UIV, T7 or T8) compared to a LT UIV. Patients with an UM UIV were then matched to patients with a UT UIV, and patients with an LM UIV were matched to patients with an LT UIV, across demographic and spinopelvic parameters. Rates of any complication, surgical complications, and reoperation were compared. Among 1145 patients, 4.6% had a midthoracic UIV. Selection for T5 or T6 UIV, as opposed to T3 or T4, was associated with less T10-L2 kyphosis (p=0.011), greater T4 pelvic angle (p=0.021), smaller L1 pelvic angle (p=0.010). Selection for T7 or T8 UIV, as opposed to T9 or T10, was associated with smaller T1 pelvic angle (p=0.001), greater L1 pelvic angle (p=0.001), greater pelvic tilt (p=0.030), more T10-L2 kyphosis (p=0.002), and less thoracic kyphosis (p=0.018). 25 patients with an UM UIV were matched to 112 patients with a UT UIV, and had the same overall rate of complications (56.0% vs 84.0%, p=0.148), and a lower rate of surgical complications (28.0% vs 72.0%, p=0.005) and reoperation (12.0% vs 44.0%, p=0.047). 24 patients with LM UIV were matched to 108 patients with LT UIV, and had a lower overall rate of complications (37.5% vs 79.2%, p=0.005) and surgical complications (12.5% vs 62.5%, p<0.001), and equal rates of reoperation (4.2% vs 20.8%, p=0.144). In a select subset of ASD patients in which a midthoracic UIV was chosen, complication rates were the same or better than fusions with an upper- or lower-thoracic UIV; however, results are likely limited by selection bias. Although some distinguishing baseline alignment factors were identified in this study, further investigation is warranted. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Lumbar degenerative disease imposes a substantial burden on global health care expenditures. Transforaminal lumbar interbody fusion (TLIF) using either traditional trajectory (TT) pedicle screws or cortical bone trajectory (CBT) pedicle screws has become increasingly common. This meta-analysis evaluated outcomes and safety of open TLIF with TT compared with CBT. PubMed, Cochrane, and Google Scholar were searched up to April 2024. The studied outcomes included complications, revision surgeries, operating room time, estimated blood loss, length of hospital stay (LOS), incision length, Visual Analog Scale, Oswestry Disability Index, and Japanese Orthopedic Association. This meta-analysis included 5 studies; 770 patients undergoing TLIF were included, with 415 in the CBT group and 355 in the TT group. No statistically significant differences were found in the rate of overall complications, including specific complications, rate of revision surgeries, patient-reported outcome measures, operating room time, and estimated blood loss. However, the CBT group demonstrated shorter LOS (P = 0.05) and shorter incision lengths (P < 0.001) compared with the TT group. TT and CBT in TLIF procedures demonstrated comparable rates of complications, reoperations, and patient-reported outcome measures. Despite similar operating room times and estimated blood loss, the CBT group exhibited shorter incision lengths and shorter LOS than the TT group. Both CBT and TT pedicle screws are safe and effective options for TLIF. There are potential benefits to CBT such as shorter incision and LOS, although TT remains an essential tool for spinal instrumentation techniques. [ABSTRACT FROM AUTHOR]

Cutibacterium acnes (C. acnes) previously named Propionibacterium acnes (P. acnes) has been increasingly recognized by spine surgeons as a cause of indolent postsurgical spinal infection. Patients infected with C. acnes may present with pseudarthrosis or nonspecific back pain. Currently, microbiological tissue cultures remain the gold standard in diagnosing C. acnes infection. Ongoing research into using genetic sequencing as a diagnostic method shows promising results and may be another future way of diagnosis. Optimized prophylaxis involves the use of targeted antibiotics, longer duration of antibiotic prophylaxis, antibacterial-coated spinal implants, and evidence-based sterile surgical techniques all of which decrease contamination. Antibiotics and implant replacement remain the mainstay of treatment, with longer durations of antibiotics proving to be more efficacious. Local guidelines must consider the surge of antimicrobial resistance worldwide when treating C. acnes. [ABSTRACT FROM AUTHOR]

The inclusion of 2 surgeons in spinal deformity surgery is considered beneficial by some. In fact, select studies indicate advantages such as reduced operation time and blood loss. Another observed decreased patient morbidity with a dual-surgeon approach, attributed to shorter operative times and reduced intraoperative blood losses. Therefore, this meta-analysis will assess the benefits of a having 2 surgeons compared to 1 surgeon during spine surgeries. PubMed, Cochrane, and Google Scholar (page 1–20) were searched till January 2024. The clinical outcomes evaluated were the incidence of adverse events, the rate of transfusion, reoperation, and surgery-related parameters such as operative room time, length of stay (LOS), and estimated blood loss. Thirteen studies were included. A greater rate of complications was seen in patients operated upon by 1 surgeon (odds ratio = 0.50; 95% confidence intervals [CI]: 0.25–0.99, P = 0.05). Furthermore, operative room time (mean differences = −82.73; 95% CI: −111.42 to −54.03, P < 0.001) and LOS (mean differences = −0.91; 95% CI: −1.12 to −0.71, P < 0.001) were reduced in the dual surgeon scenario. No statistically significant difference was shown in the remaining analyzed outcomes. The presence of 2 surgeons in the odds ratiowas shown to reduce complications, operative room time, and LOS. More cost-effectiveness studies are needed in order to substantiate the financial advantages associated with the dual-surgeon approach. [ABSTRACT FROM AUTHOR]

The social and technological mutation of our contemporary period disrupts the traditional dyad that prevails in the relationship between physicians and patients. The solicitation of a second opinion by the patient may potentially alter this dyad and degrade the mutual trust between the stakeholders concerned. The doctor-patient relationship has often been studied from the patient's perspective, but data are scarce from the spine surgeon's point of view. This qualitative study used the grounded theory approach, an inductive methodology emphasizing field data and rejecting predetermined assumptions. We interviewed spine surgeons of different ages, experiences, and practice locations. We initially contacted 30 practitioners, but the final number (24 interviews; 11 orthopedists and 13 neurosurgeons) was determined by data saturation (the point at which no new topics appeared). Themes and subthemes were analyzed using semistructured interviews until saturation was reached. Data were collected through individual interviews, independently analyzed thematically using specialized software, and triangulated by three researchers (an anthropologist, psychiatrist, and neurosurgeon). Index surgeons were defined when their patients went for a second opinion and recourse surgeons were defined as surgeons who were asked for a second opinion. Data analysis identified five overarching themes based on recurring elements in the interviews: (1) analysis of the patient's motivations for seeking a second opinion; (2) impaired trust and disloyalty; (3) ego, authority, and surgeon image; (4) management of a consultation recourse (measurement and ethics); and (5) the second opinion as an avoidance strategy. Despite the inherent asymmetry in the doctor-patient relationship, surgeons and patients share two symmetrical continua according to their perspective (professional or consumerist), involving power and control on the one hand and loyalty and autonomy on the other. These shared elements can be found in index consultations (seeking high-level care/respecting trust/closing the loyalty gap/managing disengagement) and referral consultations (objective and independent advice/trusting of the index advice/avoiding negative and anxiety-provoking situations). The second opinion often has a negative connotation with spine surgeons, who see it as a breach of loyalty and trust, without neglecting ego injury in their relationship with the patient. A paradigm shift would allow the second opinion to be perceived as a valuable resource that broadens the physician-patient relationship and optimizes the shared surgical decision-making process. [ABSTRACT FROM AUTHOR]

Anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) are commonly performed operations to address cervical radiculopathy and myelopathy. Trends in utilization and revision surgery rates warrant investigation. To explore the epidemiology, postoperative complications, and reoperation rates of ACDF and CDA. Retrospective cohort study. A total of 433,660 patients who underwent ACDF or CDA between 2011 and 2021 were included in this study. The following data were observed for all cases: patient demographics, complications, and revisions. The PearlDiver database was queried to identify patients who underwent ACDF and CDA between 2011 and 2021. Epidemiological analyses were performed to examine trends in cervical procedure utilization by age group and year. After matching by age, sex, Charlson Comorbidity Index (CCI), levels of operation, and reason for surgery, the early postoperative (2-week), short-term (2-year), and long-term (5-year) complications of both cervical procedures were examined. In total, 404,195 ACDF and 29,465 CDA patients were included. ACDF utilization rose by 25.25% between 2011 and 2014 while CDA utilization rose by 654.24% between 2011-2019 followed by relative plateauing in both procedures. Mann-Kendall trend test confirmed a significant but small rise in ACDF and large rise in CDA procedures from 2011 to 2021 (p<.001). After matching, ACDF and CDA had an overall complication rate of 12.20% and 8.77%, respectively, with the most common complications being subsequent anterior revision (4.96% and 3.35%) and dysphagia (3.70% and 2.98%). The ACDF cohort, especially multilevel ACDF patients, generally had more complications and higher revision rates than the CDA cohort (p<.05). While ACDF utilization has plateaued since 2014, CDA rates have risen by a staggering 654.24% over the past decade. ACDF and CDA complication and revision rates were relatively low in comparison to previously published values, with significantly lower rates in CDA. Although a lack of radiographic data in this study limits its power to recommend either procedure for individual patients with cervical radiculopathy or myelopathy, CDA may be associated with minor improvement in the complication and revision profile. [ABSTRACT FROM AUTHOR]

Osteoporosis (OP) is a common condition affecting nearly 200 million individuals globally. Similarly, adult spinal deformity has a peak prevalence of 65% of the adult population. While bone health is instrumental in orthopaedic surgery, few studies have described the long-term outcomes of osteoporosis following surgery for ASD. We sought to evaluate the impact of OP on two-year postoperative complication rates when compared to patients without OP. Retrospective cohort study. Utilizing the New York State Statewide Planning and Research Cooperative System (SPARCS), we identified all patients who underwent ≥4-level fusion with ICD-9 codes diagnostic for ASD (progressive idiopathic scoliosis and degenerative lumbar disease) from 2009-2011 with ≥2-year follow-up. Patients with osteoporosis (OP) and without OR were identified following exclusions. Patient demographics, hospital-related parameters, postoperative complications and reoperations. Using SPARCS, we identified all patients who underwent ≥4-level fusion with ICD-9 codes diagnostic for ASD (progressive idiopathic scoliosis and degenerative lumbar disease) from 2009-2011 for ≥2-year minimum follow-up. Patients with osteoporosis (OP) and without OP were identified. Any patients with bone mineralization disorders (osteomalacia, rickets, hyperparathyroidism [primary, secondary, tertiary], vitamin D deficiency) and other systemic (fibrous dysplasia, sickle cell disease, renal osteodystrophy) and endocrine disorders (thyroid hypo- or hyperfunctioning disorders, adrenal insufficiency, adrenal hyperplastic syndromes) affecting bone quality or production were excluded, as were patients with surgical indications of trauma, systemic disease, infection, or cancer. The two cohorts were compared for demographics, hospital-related parameters, and 2-year postoperative complications and reoperations. Multivariate binary stepwise logistic regressions was utilized to identify significant predictors of these outcomes (covariates: OP, age, sex, race, and Charlson/Deyo). A total of 6,132 patients were identified (OP, n=490 (7.99%); No-OP, n=5,642). OP patients were older (67.6 vs 56.7 years), more often female (83.7% vs 46.2%) and white (84.3% vs 79.1%), and had higher comorbidity scores (Charlson/Deyo: 0.72 vs 0.61), all p<0.05. Patients with OP incurred higher hospital charges ($122,801 vs $108,649) and length of stay (6.7 days vs 5.8 days), both p<0.001. OP patients had higher rates of postop wound complications (13.5% vs 10.6%), acute renal failure (12.2% vs 7.90%), pseudarthrosis (3.7% vs 1.4%), blood transfusions (54.3% vs 34.6%), pneumonia (10.4% vs 6.1%), and implant-related complications (22.4% vs 14.5%); all p≤0.047. Patients in OP and no-OP cohorts experienced similar rates of postop PE, DVT, acute myocardial infarction, pneumonia, UTIs, dural tears, and CNS complications. Regression revealed that while controlling for demographics and comorbidities, OP is independently associated with increased odds of 2-year medical complications (OR=1.46), surgical complications (OR=1.55), and reoperations (OR=1.46); all p≤0.024. Osteoporosis was associated with two-year postoperative complications in ASD patients. Aside from being an etiology of ASD due to vertebral fracture, osteoporosis should be considered as a comorbidity that needs to be optimized and managed perioperatively. Furthermore, this data is a call to every spine surgeon to consider metabolic bone disorders screening prior to any spinal deformity surgery. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

It is incompletely understood how preoperative resilience affects 1-year postoperative outcomes after lumbar spinal fusion. Patients undergoing open lumbar spinal fusion at a single-center institution were identified between November 2019 and September 2022. Preoperative resilience was assessed using the Brief Resilience Scale. Demographic data at baseline including age, gender, comorbidities, and body mass index (BMI) were extracted. Patient-reported outcome measures including Oswestry Disability Index, PROMIS (Patient-Reported Outcomes Measurement Information System) Global Physical Health, PROMIS Global Mental Health (GMH), and EuroQol5 scores were collected before the surgery and at 3 months and 1 year postoperatively. Bivariate correlation was conducted between Brief Resilience Scale scores and outcome measures at 3 months and 1 year postoperatively. Ninety-three patients had baseline and 1 year outcome data. Compared with patients with high resilience, patients in the low-resilience group had a higher percentage of females (69.4% vs. 43.9%; P = 0.02), a higher BMI (32.7 vs. 30.1; P = 0.03), and lower preoperative Global Physical Health (35.8 vs. 38.9; P = 0.045), GMH (42.2 vs. 49.2; P < 0.001), and EuroQol scores (0.56 vs. 0.61; P = 0.01). At 3 months postoperatively, resilience was moderately correlated with GMH (r = 0.39) and EuroQol (r = 0.32). Similarly, at 1 year postoperatively, resilience was moderately correlated with GMH (r = 0.33) and EuroQol (r = 0.34). Comparable results were seen in multivariable regression analysis controlling for age, gender, number of levels fused, BMI, Charlson Comorbidity Index, procedure, anxiety/depression, and complications. Low preoperative resilience can negatively affect patient-reported outcomes 1 year after lumbar spinal fusion. Resiliency is a potentially modifiable risk factor, and surgeons should consider targeted interventions for at-risk patient groups. [ABSTRACT FROM AUTHOR]

Among adult spinal deformity (ASD) patients, heterogeneity in patient pathology, surgical expectations, baseline impairments, and frailty complicates comparisons in clinical outcomes and research. This study aims to qualitatively segment ASD patients using machine learning-based clustering on a large, multicenter, prospectively gathered ASD cohort. To qualitatively segment adult spinal deformity patients using machine learning-based clustering on a large, multicenter, prospectively gathered cohort. Machine learning algorithm using patients from a prospective multicenter study and a validation cohort from a retrospective single center, single surgeon cohort with complete 2-year follow up. About 805 ASD patients; 563 patients from a prospective multicenter study and 242 from a single center to be used as a validation cohort. To validate and extend the Ames-ISSG/ESSG classification using machine learning-based clustering analysis on a large, complex, multicenter, prospectively gathered ASD cohort. We analyzed a training cohort of 563 ASD patients from a prospective multicenter study and a validation cohort of 242 ASD patients from a retrospective single center/surgeon cohort with complete two-year patient-reported outcomes (PROs) and clinical/radiographic follow-up. Using k-means clustering, a machine learning algorithm, we clustered patients based on baseline PROs, Edmonton frailty, age, surgical history, and overall health. Baseline differences in clusters identified using the training cohort were assessed using Chi-Squared and ANOVA with pairwise comparisons. To evaluate the classification system's ability to discern postoperative trajectories, a second machine learning algorithm assigned the single-center/surgeon patients to the same 4 clusters, and we compared the clusters' two-year PROs and clinical outcomes. K-means clustering revealed four distinct phenotypes from the multicenter training cohort based on age, frailty, and mental health: Old/Frail/Content (OFC, 27.7%), Old/Frail/Distressed (OFD, 33.2%), Old/Resilient/Content (ORC, 27.2%), and Young/Resilient/Content (YRC, 11.9%). OFC and OFD clusters had the highest frailty scores (OFC: 3.76, OFD: 4.72) and a higher proportion of patients with prior thoracolumbar fusion (OFC: 47.4%, OFD: 49.2%). ORC and YRC clusters exhibited lower frailty scores and fewest patients with prior thoracolumbar procedures (ORC: 2.10, 36.6%; YRC: 0.84, 19.4%). OFC had 69.9% of patients with global sagittal deformity and the highest T1PA (29.0), while YRC had 70.2% exhibiting coronal deformity, the highest mean coronal Cobb Angle (54.0), and the lowest T1PA (11.9). OFD and ORC had similar alignment phenotypes with intermediate values for Coronal Cobb Angle (OFD: 33.7; ORC: 40.0) and T1PA (OFD: 24.9; ORC: 24.6) between OFC (worst sagittal alignment) and YRC (worst coronal alignment). In the single surgeon validation cohort, the OFC cluster experienced the greatest increase in SRS Function scores (1.34 points, 95%CI 1.01–1.67) compared to OFD (0.5 points, 95%CI 0.245–0.755), ORC (0.7 points, 95%CI 0.415–0.985), and YRC (0.24 points, 95%CI -0.024–0.504) clusters. OFD cluster patients improved the least over 2 years. Multivariable Cox regression analysis demonstrated that the OFD cohort had significantly worse reoperation outcomes compared to other clusters (HR: 3.303, 95%CI: 1.085–8.390). Machine-learning clustering found four different ASD patient qualitative phenotypes, defined by their age, frailty, physical functioning, and mental health upon presentation, which primarily determines their ability to improve their PROs following surgery. This reaffirms that these qualitative measures must be assessed in addition to the radiographic variables when counseling ASD patients regarding their expected surgical outcomes. [ABSTRACT FROM AUTHOR]

Spinal and body balance are active processes requiring a thorough understanding of the harmony between static posture and dynamic motion. Our understanding of patients' function is lacking a more objective and quantified mechanism of assessment. The Dubousset Functional Test (DFT) is a four-component, novel, multidomain physical function and balance assessment proposed by Dr. Jean Dubousset. To identify normative baseline/reference values for DFT in asymptomatic, healthy subjects, establish test feasibility, and identify correlations between demographics and DFT performance in the general population. Prospective single-center. Sixty-five asymptomatic volunteers (mean age: 42.4±15.4 years; 42% female, mean BMI 26±4.8kg/m2). Demographics, DFT components: Up-and-Walking Test (UWT), Steps Test (ST), Down-and-Sitting Test (DST), Dual-Tasking Test (DTT). Asymptomatic volunteers were screened and recruited to participate in the 4 DFT components at a single center from 2017-2018. These include: (1) UWT (Up-and-Walking Test): unassisted sit-to-stand, walk forward/backward 5 m (no turn), unassisted sit; (2) ST (Steps Test): ascend 3 steps, turn, descend 3 steps; (3) DST (Down-and-Sitting Test): stand-to-ground sit-to-stand, assistance as needed; (4) DTT (Dual-Tasking Test): walk 5 m forth and back while counting down from 50 by 2. All subjects were given standardized verbal instructions and a physical demonstration for each DFT test. Trials were video recorded and timed, with scores assigned by time required to complete the test. All trials were conducted and all tests were scored by the same rater. Univariate and multivariate analysis were utilized to analyze durations of test components against demographics. 65 subjects were included (mean age, 42.4±15.4 years); 42% were female, and mean BMI was 26±4.8 kg/m^2. The racial breakdown of the cohort was 34% White, 25% Black, 15% Asian, 9% Indian, 6% Latino, 10% other. Evaluating the four components of the DFT, the mean and standard deviations of each test component were as follows: mean duration in seconds and 95% confidence interval of each DFT test: UWT: 14.8s (14.0-15.6s), ST: 6.3s (6.0-6.6s), DST: 6.0s (5.4-6.6s), and DTT: 12.8s (12.1-13.6s). There were no differences between males and females in time taken to perform any of the tests. There were significant correlations between age and DST (r=0.529), UWT (r=0.429), and ST (r=0.356) (all p<0.05), with no correlation found with DTT. A similar trend was found with respect to correlation with BMI (r=0.372, r=0.289, and r=0.366, p<0.05), with no correlation again found with DTT. With respect to DTT specifically, patients on average finished countdown from 50 to 29.7±5.3. 12.3% of subjects exhibited physical pausing during the DTT, and 87.5% of those were pauses occurred while turning. Among total subjects, 32.3% exhibited verbal pausing/stuttering/mistakes in counting during the Dual Tasking test; of these, 62% occurred while turning. The DFT is a quick and feasible test that was performed safely in a cohort of healthy subjects. Age and BMI, but not gender, were found to influence all DFT tests. Physical and verbal pausing were reported in about 1/10 and 1/3 patients, respectively, with the majority of pausing occurring during the turning phase of the test. Utilization of this test in patients with spinal pathologies may help us to determine the offset from norms as well as understand the impact of preoperative DFT performance on surgical outcomes. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Previous studies have demonstrated that adult cervical deformity patients may be at increased risk of death in conjunction with increased frailty or a weakened physiologic state. However, such studies have often been limited by follow-up duration, and longer-term studies are needed to better assess temporal changes in ACD patients and associated mortality risk. To assess if patients with decreased comorbidities and physiologic burden will be at lessened risk of death for a greater length of time after undergoing adult cervical deformity surgery. Retrospective review. Two hundred ninety ACD patients. Morbidity and mortality data. Operative ACD patients ≥18 years with pre-(BL) and 10-year (10Y) data were included. Patients were stratified as expired versus living, as well as temporally grouped by Expiration prior to 5Y or between 5Y and 10Y. Group differences were assessed via means comparison analysis. Backstep logistic regression identified mortality predictors. Kaplan-Meier analysis assessed survivorship of expired patients. Log rank analysis determined differences in survival distribution groups. Sixty-six total patients were included (60.97±10.19 years, 48% female, 28.03±7.28 kg/m2). Within 10Y, 12 (18.2% of ACD cohort) expired. At baseline, patients were comparable in age, gender, BMI, and CCI total on average (all p>.05). Furthermore, patients were comparable in BL HRQLs (all p>.05). However, patients who expired between 5Y and 10Y demonstrated higher BL EQ5D and mJOA scores than their earlier expired counterparts at 2Y (p<.021). Furthermore, patients who presented with no CCI markers at BL were significantly more likely to survive until the 5Y-10Y follow-up window. Surgically, the only differences observed between patients who survived until 5Y was in undergoing osteotomy, with longer survival seen in those who did not require it (p=.003). Logistic regression revealed independent predictors of death prior to 5Y to be increased BMI, increased frailty, and increased levels fused (model p<.001). KM analysis found that by Passias et al frailty, not frail patients had mean survival time of 170.56 weeks, versus 158.00 in frail patients (p=.949). Our study demonstrates that long-term survival after cervical deformity surgery may be predicted by baseline surgical factors. By optimizing BMI, frailty status, and minimizing fusion length when appropriate, surgeons may be able to further assist ACD patients in increasing their survivability postoperatively. [ABSTRACT FROM AUTHOR]

As of 2021, the Centers for Medicare and Medicaid Services (CMS) requires all hospitals to publish their commercially negotiated prices. To our knowledge, price variation of spine oncology diagnosis and treatments has not been previously investigated. The aim of this study is to characterize the availability and variation of prices for spinal oncology services among National Cancer Institute-Designated Cancer Centers (NCI-DCC). Cross-sectional analysis. Cancer centers were identified; those that did not provide patient care or participate in Medicare's Inpatient Prospective System were excluded. A cross-sectional analysis was conducted to gather commercially negotiated prices by searching online for "[center name] price transparency OR machine-readable file OR chargemaster." Data obtained was queried using 44 current procedural terminology (CPT) codes for imaging, procedures, and surgeries relevant to spine oncology. Comparison of prices was achieved by normalizing the median price for each service at each center to the estimated 2022 Medicare reimbursement for the center's Medicare Administrator Contractor. The ratios between the lowest and highest median commercial negotiated price within a center and across all centers were defined as "within-center ratio" and "across-center ratio" respectively. In total, 49 centers disclosed commercial payer-negotiated rates. Mean rate (±SD) for cervical corpectomy was $9,134 (±$10,034), thoracic laminectomy for neoplasm excision was $5,382 (±$5502), superficial bone biopsy was $1,853 (±$1,717), and single-photon emission computerized tomography (SPECT) was $813 (±$232). Within-center ratios ranged from 5.0 (SPECT scan) to 17.8 (radiofrequency bone ablation). Across-center ratios (for codes with > 10 centers reporting) ranged from 9.0 (corpectomy, thoracic, lateral extra-cavitary) to 418.7 (anterior approach cervical corpectomy). Price transparency for spinal oncology remains elusive despite recent CMS regulatory oversight, with marked heterogeneity in the quality of published rates complicating patients' ability to "shop" for care. Additionally, there continues to be significant variation in commercial rates for spine oncology diagnosis and treatment. Despite regulation by CMS, prices for spinal oncology services are not uniformly available to patients and vary between NCI-DCC. The findings of this manuscript present potential barriers for patients to compare and obtain affordable care. [ABSTRACT FROM AUTHOR]

The aim of this study, a retrospective database analysis, was to assess the impact of baseline cannabis use disorder (CUD) on perioperative complication outcomes in patients undergoing primary 1- to 2-level anterior cervical diskectomy and fusion (ACDF) surgery. The PearlDiver Database was queried from January 2010 to December 2021 for patients who underwent primary 1- to 2-level ACDF surgery for degenerative spine disease. Patients with CUD diagnosis 6 months before the index ACDF surgery (i.e., CUD) were propensity matched with patients without CUD (i.e., control in a ratio of 1:1, employing age, gender, and Charlson Comorbidity Index as matching covariates). Univariate and multivariable analysis models with adjustment of confounding variables were used to evaluate the risk of CUD on perioperative complications between the propensity-matched cohorts. The 1:1 matched cohort included 838 patients in each group. Following multivariate analysis, CUD was demonstrated to be associated with an increased incidence of hospital readmission at 90 days (odds ratio [OR] = 2.64, 95% confidence interval: [1.19 to 6.78], [ P = 0.027]) and revision surgery at 1 year postoperative (OR = 3.36, 95% confidence interval: [1.17 to 14.18], [ P = 0.049]). CUD was additionally associated with reduced risk of overall medical complications at both 6 months and 1 year postoperative (OR = 0.55, [ P = 0.021], and OR = 0.54, [ P = 0.015], respectively). These findings indicate that isolated baseline CUD is associated with an increased risk of hospital readmission at 90 days postoperative and cervical spine reoperation at 1 year after primary 1- to 2-level ACDF surgery with a decrease in overall medical complications, cardiac arrhythmias, and acute renal failure. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Recently, there has been increased recognition of the interplay between degenerative conditions of the hip and spine (Hip-Spine Syndrome, HiSS). Loss of lumbar lordosis (LL) of more than 10° in proportion to the pelvic incidence (PI), PI-LL mismatch, has been emphasized as a marker of sagittal spinal malalignment. The impact of positive spinal sagittal malalignment on increased hip extension (pelvic posterior tilt in spinal literature) and subsequently the acetabular version is established. Communication between adult hip reconstruction and spinal deformity surgeons regarding HiSS is ineffective without common language, an established definition, or mutual radiographic imaging protocols. PURPOSE This study aimed to characterize various presentations of HiSS and suggest a simple method to distinguish between them. STUDY DESIGN/SETTING Retrospective review of a prospectively collected adult spinal deformity database. PATIENT SAMPLE A total of 1,389 patients who presented to a single center with orthopaedic complaints between 2013 and 2016. OUTCOME MEASURES Demographics, parameters related to spinopelvic alignment (PI, PT, LL, PI-LL), global spinal alignment (TPA, SVA, GSA), and lower extremities (SFA, KF, pelvic shift) from full-body sagittal radiographic imaging, and Kellgren–Lawrence grade. METHODS Demographic information was collected and full-body (FB) sagittal radiographs were analyzed using dedicated software to measure spinopelvic, global sagittal spinal alignment, lower extremity, and FB sagittal radiographic parameters. FB coronal radiographs were analyzed by two reviewers to assess hip osteoarthritis (HOA) via Kellgren–Lawrence grade. Patients were grouped based on their sagittal spinal alignment (PI-LL mismatch) and HOA into: HiSS None (PI LL<10°, HOA Grade 0; n=444), HiSS Hip (PI-LL<10°, HOA Grades 3–4; n=75), HiSS Spine (PI-LL>10°, HOA Grade 0; n=297), or HiSS Hip-Spine (PI-LL>10°, HOA Grades 3–4; n=30). All radiographic parameters were compared between the groups. P-values were Bonferroni method-adjusted. Significance level was set at p<.05. RESULTS A total of 1,389 patients were included with a mean age of 62.5±11.1 years and mean BMI of 27.6±5.7kg/m2. A total of 62% of the study population was female. HiSS Hip-Spine (n=30) had significantly greater pelvic posterior tilt (sagittal retroversion) in comparison to HiSS Hip (n=78) and HiSS None Types (n=444) (25.2° vs. 11.3° and 16.5°, respectively; p<.001) and more hip extension as measured by the sacrofemoral angle (23.1° vs. 19.5° and 10.1°, respectively; p<.001). HiSS Hip-Spine had significantly less lumbar lordosis (40.9° vs. 57.0° and 54.2°, respectively), greater knee flexion (9° vs. 6.4° and 2.6°, respectively) and positive sagittal spinal malalignment (SVA) (57.2 vs. 28.4 and 7.8mm, respectively) (all p<.001) than HiSS Hip and HiSS None. On the other hand, HiSS Hip-Spine Type had also distinctive measures in comparison to HiSS Spine. HiSS Hip-Spine had significantly lower pelvic posterior tilt (25.2° vs. 29.2°, p<.001), hip extension (23.1° vs. 28.4°, p<.001) despite having comparable spinopelvic PI-LL mismatch (21.4° vs. 24.2°, p>.05). CONCLUSIONS This study proposes a novel HiSS categorization system based on established spinal deformity and HOA classification methods. Radiographically, HiSS Hip-Spine Type patients can be distinguished by Adult Reconstructive Surgeons by measuring pelvic tilt angle. Increased PT>25° in HOA patients is a marker for sagittal spinal deformity that has the potential to impact acetabular version. [ABSTRACT FROM AUTHOR]