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• 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]

• 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]

• 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]

• Identification of predictors of extended op-time and length of stay in CD patients. • Levels fused, surgical approach, BMI and osteotomy predicted op-time and LOS. • Baseline cSVA and C0 slope predicted increased LOS and op-time. • Patient care, hospital efficiency, and resource allocation can be optimized. It's increasingly common for surgeons to operate on more challenging cases and higher risk patients, resulting in longer op-time and inpatient LOS. Factors predicting extended op-time and LOS for cervical deformity (CD) patients are understudied. This study identified predictors of extended op-time and length of stay (LOS) after CD-corrective surgery. CD patients with baseline (BL) radiographic data were included. Patients were stratified by extended LOS (ELOS; >75th percentile) and normal LOS (N-LOS; <75th percentile). Op-time analysis excluded staged cases, cases >12 h. A Conditional Variable Importance Table used non-replacement sampling set of Conditional Inference trees to identify influential factors. Mean comparison tests compared LOS and op-time for top factors. 142 surgical CD patients (61 yrs, 62%F, 8.2 levels fused). Op-time and LOS were 358 min and 7.2 days; 30% of patients experienced E-LOS (14 ± 13 days). Overlapping predictors of E-LOS and op-time included levels fused (>7 increased LOS 2.7 days; >5 increased op-time 96 min, P < 0.001), approach (anterior reduced LOS 3.0 days; combined increased op-time 69 min, P < 0.01), BMI (>38 kg/m2 increased LOS 8.1 days; >39 kg/m2 increased op-time 17 min), and osteotomy (LOS 2.0 days, op-time 62 min, P < 0.005). BL cervical parameters increased LOS and op-time: cSVA (>42 mm increased LOS; >50 mm increased op-time, P < 0.030), C0 slope (>@−0.9° increased LOS, >0.3° increased op-time, P < 0.003.) Additional op-time predictors: prior cervical surgery (p = 0.004) and comorbidities (P = 0.015). Other predictors of E-LOS: EBL (P < 0.001), change in mental status (P = 0.001). Baseline cervical malalignment, levels fused, and osteotomy predicted both increased op-time and LOS. These results can be used to better optimize patient care, hospital efficiency, and resource allocation. [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]

Abstract Interest in the application of bundled payments to the field of spine surgery continues to grow. There may be great potential for cost-savings for spinal procedures under bundled payments. However, challenges such as heterogeneity of DRGs, complex procedures requiring lengthy recoveries, and appropriate outcomes measurement pose barriers to successful bundled payment design. In this paper, we review the challenges and opportunities posed by bundled payments in spine surgery. We also present several key considerations for policymakers interested in payment reform within spine surgery. Surgeon involvement will be critical in providing guidance for generating effective alternative payment models. [ABSTRACT FROM AUTHOR]

Highlights • Created a model to find risk factors for complications in cervical deformity surgery. • 64.2% of patients sustained any complication. • Most reliable predictor of the occurrence of a complication involved multiple factors. • Radiographic baseline sagittal cervical SVA was the strongest isolated predictor. Abstract We developed a predictive model to describe risk factors for complications in cervical deformity surgeries. Cervical deformity (CD) surgical patients are growing in number, but remain under-studied in the literature. CD was defined as at least one of the following: C2–C7 Cobb >10°, CL >10°, cSVA >4 cm, CBVA >25°. Patient demographics and clinical data were assessed as risk factors for medical/surgical complications using multivariate regression models. 123 patients underwent CD surgery (60.6 yrs, 60.8% F). The most common complications were neurologic (24.4%), dysphagia (13.0%), cardiopulmonary (11.4%), infection (9.7%). 51 (41.5%) of patients experienced a medical complication and 73 (59.3%) had a surgical complication. An overall complication was predicted with high accuracy (AUC = 0.79) by the following combinations of factors: higher baseline EQ5D pain and lower baseline EQ5D anxiety/depression scores, and higher cervical and global SVA. A medical complication can be predicted by male gender, baseline mJOA score, and cervical SVA (AUC = 0.770). A surgical complication can be predicted by higher estimated blood loss, lower anxiety scores, and larger global SVA (AUC = 0.739). 64.2% of patients undergoing cervical deformity correction sustained any complication. While the most reliable predictor of the occurrence of a complication involved a cluster of risk factors, a radiographic baseline sagittal parameter of cervical SVA was the strongest isolated predictor for complications across categories. Although these findings are specific to a cervical population with moderate to severe deformities, collectively they can be utilized for pre-operative risk assessment and patient education. [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]

Background The impact of obesity on global spinopelvic alignment is poorly understood. This study investigated the effect of body mass index on achieving alignment targets and compensation mechanisms after corrective surgery for adult spinal deformity (ASD). Methods Retrospective review of a single-center database. Inclusion: patients ≥18 years with full-body stereographic images (baseline and 1 year) and who met ASD criteria (sagittal vertical axis [SVA] >5 cm, pelvic incidence minus lumbar lordosis [PI–LL] >10°, coronal curvature >20° or pelvic tilt >20°). Patients were stratified by age (<40, 40–65, and ≥65 years) and body mass index (<25, 25–30, and >30). Postoperative alignment was compared with age-adjusted ideal values. Prevalence of patients who matched ideals and unmatched (undercorrected/overcorrected) was assessed. Health-related quality of life (HRQL) scores, alignment, and compensatory mechanisms were compared across cohorts using analysis of variance and temporally with paired t tests. Results A total of 116 patients were included (average age, 62 years; 66% female). After corrective surgery, obese and overweight patients had more residual malalignment (worse PI–LL, T1 pelvic angle, pelvic tilt, and SVA) compared with normal patients (P < 0.05). In addition, obese and overweight patients recruited more pelvic shift (obese, 62.36; overweight, 49.80; normal, 31.50) and had a higher global sagittal angle (obese, 6.51; overweight, 6.35; normal, 3.40) (P < 0.05). Obese and overweight patients showed lower overcorrection rates and higher undercorrection rates (P < 0.05). Obese patients showed worse postoperative HRQL scores (Scoliosis Research Society 22 Questionnaire, Oswestry Disability Index, visual analog scale–leg) than did overweight and normal patients (P < 0.05). Obese and overweight patients who matched age-adjusted alignment targets for SVA or PI–LL showed no HRQL improvements (P > 0.05). Conclusions After surgery, obese patients were undercorrected, showed more residual malalignment, recruited more pelvic shift, and had a greater global sagittal angle and worse HRQL scores. The benefits from age-adjusted alignment targets seem to be less substantial for obese and overweight patients. Highlights • Obese patients had more residual malalignment after corrective surgery. • Obese patients had greater variation on lower-extremity compensation mechanisms. • Obese patients recruited more pelvic shift and had a greater global sagittal angle. • Obese patients had worse health-related quality-of-life scores. [ABSTRACT FROM AUTHOR]

Highlights • A large proportion of patients with Chiari malformation have at least one concurrent anomaly. • Common neurologic associations include tethered cord, syringomyelia and hydrocephalus. • Additional body systems are often involved with worsening hind brain defects. Abstract Chiari malformations are structural defects in the posterior fossa where the cerebellum displaces caudally into the foramen magnum and upper spinal canal. These malformations are classified by severity as Types 1–4, each presenting with different associated and/or concurrent conditions and anomalies. The aim of this study was to utilize a nationwide database to study patients with Chiari malformations including their concurrent diagnoses and associated anomalies. Using a retrospective review of the Nationwide Inpatient Sample (NIS) database from 2003 to 2012, Chiari malformations were assessed by Chiari type and rates of concurrence for various additional anomalies were evaluated using cross-tabulations. There were 305,726 national cases of Chiari Type 1, 119,632 cases of Chiari Type 2, 15,540 cases of Type 3, and 79,663 cases of Type 4. Overall 44.3% of Chiari patients have at least one concurrent anomaly. Stratified by Chiari Type, 7.1% of Type 1 patients, 12.3% of Type 2, and 100% of Type 3 and 4 have at least one concurrent anomaly. The most common isolated neurologic associations were tethered cord, syringomyelia, and hydrocephalus, while the most common anomaly clusters were syringomyelia and scoliosis in Type 1 (0.63), tethered cord syndrome and scoliosis (0.72%) in Type 2, encephalocele and acquired hydrocephalus (11.45%) in Type 3, and reduction deformity of the brain with acquired hydrocephalus (15.95%) in Type 4. Chiari malformations have strong associations with other abnormalities outside of known relationships in the current classification. While neurologic abnormalities are most common, additional body systems are frequently involved especially with worsening hindbrain defects. [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]

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]

Background Context: Complication rates for adult cervical deformity are poorly characterized given the complexity and heterogeneity of cases.Purpose: To compare perioperative complication rates following adult cervical deformity corrective surgery between a prospective multicenter database for patients with cervical deformity (PCD) and the Nationwide Inpatient Sample (NIS).Study Design/setting: Retrospective review of prospective databases.Patient Sample: A total of 11,501 adult patients with cervical deformity (11,379 patients from the NIS and 122 patients from the PCD database).Outcome Measures: Perioperative medical and surgical complications.Methods: The NIS was queried (2001-2013) for cervical deformity discharges for patients ≥18 years undergoing cervical fusions using International Classification of Disease, Ninth Revision (ICD-9) coding. Patients ≥18 years from the PCD database (2013-2015) were selected. Equivalent complications were identified and rates were compared. Bonferroni correction (p<.004) was used for Pearson chi-square. Binary logistic regression was used to evaluate differences in complication rates between databases.Results: A total of 11,379 patients from the NIS database and 122 patiens from the PCD database were identified. Patients from the PCD database were older (62.49 vs. 55.15, p<.001) but displayed similar gender distribution. Intraoperative complication rate was higher in the PCD (39.3%) group than in the NIS (9.2%, p<.001) database. The PCD database had an increased risk of reporting overall complications than the NIS (odds ratio: 2.81, confidence interval: 1.81-4.38). Only device-related complications were greater in the NIS (7.1% vs. 1.1%, p=.007). Patients from the PCD database displayed higher rates of the following complications: peripheral vascular (0.8% vs. 0.1%, p=.001), gastrointestinal (GI) (2.5% vs. 0.2%, p<.001), infection (8.2% vs. 0.5%, p<.001), dural tear (4.1% vs. 0.6%, p<.001), and dysphagia (9.8% vs. 1.9%, p<.001). Genitourinary, wound, and deep veinthrombosis (DVT) complications were similar between databases (p>.004). Based on surgicalapproach, the PCD reported higher GI and neurologic complication rates for combined anterior-posterior procedures (p<.001). For posterior-only procedures, the NIS had more device-related complications (12.4% vs. 0.1%, p=.003), whereas PCD had more infections (9.3% vs. 0.7%, p<.001).Conclusions: Analysis of the surgeon-maintained cervical database revealed higher overall and individual complication rates and higher data granularity. The nationwide database may underestimate complications of patients with adult cervical deformity (ACD) particularly in regard to perioperative surgical details owing to coding and deformity generalizations. The surgeon-maintained database captures the surgical details, but may underestimate some medical complications. [ABSTRACT FROM AUTHOR]

Background Recent studies show increases in cervical spine surgery prevalence and cervical spondylotic myelopathy (CSM) diagnoses in the US. However, few studies have examined outcomes for CSM surgical management, particularly on a nationwide scale. Objective Evaluate national trends from 2001 to 2010 for CSM patient surgical approach, postoperative outcomes, and hospital characteristics. Methods A retrospective nationwide database analysis provided by the Nationwide Inpatient Sample (NIS) including CSM patients aged 25+ who underwent anterior and/or posterior cervical fusion or laminoplasty from 2001 to 2010. Patients with fractures, 9+ levels fused, or any cancer were excluded. Measures included demographics, hospital data, and procedure-related complications. Yearly trends were analyzed using linear regression modeling. Results 54,348 discharge cases were identified. ACDF, posterior only, and combined anterior/posterior approach volumes significantly increased from 2001 to 2010 (98.62%, 303.07%, and 576.19%; respectively, p < 0.05). However, laminoplasty volume remained unchanged ( p > 0.05). Total charges for ACDF, posterior only, combined anterior/posterior, and laminoplasty approaches all significantly increased (138.72%, 176.74%, 182.48%, and 144.85%, respectively; p < 0.05). For all procedures, overall mortality significantly decreased by 45.34% ( p = 0.001) and overall morbidity increased by 33.82% ( p = 0.0002). For all procedures except ACDF, which saw a significantly decrease by 8.75% ( p < 0.0001), length of hospital stay was unchanged. Conclusions For CSM patients between 2001 and 2010, combined surgical approach increased sixfold, posterior only approach increased threefold, and ACDF doubled; laminoplasties without fusion volume remained the same. Mortality decreased whereas morbidity and total charges increased. Length of stay decreased only for ACDF approach. This study provides clinically useful data to direct future research, improving patient outcomes. [ABSTRACT FROM AUTHOR]

Objective This is a nationwide query into surgical management techniques for tethered cord syndrome, focusing on patient demographic, hospital characteristics, and treatment outcomes. Our hypothesis is that detethering vs. fusion for TCS results in different in-hospital complications. Materials and methods Retrospective review of the Nationwide Inpatient Sample 2001–2010. Inclusion: TCS discharges undergoing detethering or fusion. Sub-analysis compared TCS cases by age (pediatric [≤9 years] vs. adolescent [10–18 year]). Independent t -tests identified differences between fusion and detethering for hospital-related and surgical factors; multivariate analysis investigated procedure as a risk factor for complications/mortality. Results 6457 TCS discharges: 5844 detetherings, 613 fusions. Fusion TCS had higher baseline Deyo Index (0.16 vs. 0.06), procedure-related complications (21.3% vs. 7.63%), and mortality (0.33% vs. 0.09%) than detethering, all p < 0.001. Detethering for TCS was a significant factor for reducing mortality (OR 0.195, p < 0.001), cardiac (OR 0.27, p < 0.001), respiratory (OR 0.26, p < 0.001), digestive system (OR 0.32, p < 0.001), puncture nerve/vessel (OR 0.56, p = 0.009), wound (OR 0.25, p < 0.001), infection (OR 0.29, p < 0.001), posthemorrhagic anemia (OR 0.04, p = 0.002), ARDS (OR 0.13, p < 0.001), and venous thrombotic (OR 0.53, p = 0.043) complications. Detethering increased nervous system (OR 1.34, p = 0.049) and urinary (OR 2.60, p < 0.001) complications. Adolescent TCS had higher Deyo score (0.08 vs. 0.03, p < 0.001), LOS (5.77 vs. 4.13 days, p < 0.001), and charges ($54,592.28 vs. $33,043.83, p < 0.001), but similar mortality. Adolescent TCS discharges had increased prevalence of all procedure-related complications, and higher overall complication rate (11.10% vs. 5.08%, p < 0.001) than pediatric. Conclusions With fusion identified as a significant risk factor for mortality and multiple procedure-related complications in TCS surgical patients, this study could aid surgeons in counseling TCS patients to optimize outcomes. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Frailty is a relatively new medical concept defined as decreased physiologic reserve and vulnerability to hospitalization. Little is known of frailty's role in traumatic odontoid fractures (C2fx), regarding mechanisms-of-traumatic-injury (MOI) and susceptibility to multiple fxs. PURPOSE Investigate the relationship between patient frailty status and traumatic MOIs. STUDY DESIGN/SETTING Retrospective review of a single-center C2fx database. PATIENT SAMPLE A total of 70 odontoid fx patients. OUTCOME MEASURES Modified frailty index (mFI), serum blood lab test results, concurrent injury rates. METHODS C2fx Patients>=65y/o with an adult traumatic odontoid fx were included. Age, gender, race, charlson comorbidity score (CCI), modified frailty index (mFI, scored from 0-1; [pre-frail <0.2 and >0] [frail>=0.2]) and injury mechanisms were assessed. ANOVA analysis determined differences in mFI among varying MOIs (falls, low speed MVA, high speed MVA, pedestrian vs. car). Logistic regression models (covariates: age, gender, CCI, lymphocyte count, frailty) determined the odds of being injured by a traumatic fall, as well as concurrent injury risk in patients with traumatic falls. RESULTS A total of 70 patients were included (mean age: 80.6±8.5; gender: 60%F; 88% European, 10% Maori/Pacific, 1.4% Asian; CCI 5.3±2.2; mFI 0.21±0.15). The most common MOIs were falls (74.3%), high speed MVAs (17.1%), low speed MVAs (5.7%) and pedestrian versus car (2.9%). Patients with traumatic falls exhibited significantly higher mFI scores (0.25) compared to low speed MVAs (0.16), high speed MVAs (0.08) and pedestrian versus car (0.01) (p=.003). Patients with falls also had lower lymphocyte counts (1.3vs. 2.9vs. 1.5vs. 1.9, p=.033) compared to all MOIs, and higher CCI (5.7vs. 3.0vs. 3.8, p=.018) compared to high speed MVAs and pedestrian versus car accidents. 'Frail' patients were at higher risk of being injured via a traumatic fall (OR: 29.167[4.044–210.354], p=.001) (R2: 0.486). Of the patients with traumatic falls (n=52), 16 (30.8%) had cervical concurrent injuries, while 0 patients had noncervical concurrent injuries. mFI was not associated with an increased risk of concurrent cervical spine fractures(p=.612). CONCLUSIONS Patients with traumatic odontoid fx from falls were 29 times more likely to be frail compared to any other MOI. Physicians and patients alike should be aware of the association between elevated frailty scores and odontoid fxs from traumatic falls. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Conflicting reports exist in spine literature regarding short-term outcomes following cervical laminoplasty and posterior laminectomy and fusion. PURPOSE The objective of this study was to compare the 30-day outcomes for these two treatment groups for multilevel cervical pathology. STUDY DESIGN/SETTING Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database years 2010-2015. PATIENT SAMPLE A total of 3,796 patients were included: 2,397 (63%) underwent cervical laminectomy and fusion and 1,399 (37%) underwent cervical laminoplasty. OUTCOME MEASURES Patient demographics, comorbidities, complications and outcomes compared between patients undergoing cervical laminoplasty or laminectomy and fusion. METHODS Patients who underwent cervical laminoplasty or posterior laminectomy and fusion were identified in the NSQIP database from 2010 to 2015 based on Current Procedural Terminology (CPT) code. Laminoplasty CPT codes included 63050 and 63051. Posterior cervical laminectomy CPT codes included 63015, 63045, and instrumentation was denoted by CPT code 22842. Patients with preoperative sepsis, wound infection, pneumonia, cancer, emergency cases and trauma, and surgery within the last 30days were excluded. Patient demographics and comorbidities were compared using bivariate logistic regression. Propensity-adjusted multivariate regressions were performed to assess differences in postoperative length of stay, adverse events, discharge disposition and readmission. RESULTS A total of 3,796 patients were included: 2,397 (63%) underwent cervical laminectomy and fusion and 1,399 (37%) underwent cervical laminoplasty. Both groups were similar in age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) score and Charlson Comorbidity Index (CCI) (P>.05 for all). Both groups had similar rates of malnutrition, chronic kidney disease (CKD), diabetes, chronic obstructive pulmonary disease, and history for steroid use. Age >70 and age <50 were not associated with one treatment group over the other (P>.05 for all). Compared with laminoplasty patients, laminectomy and fusion patients had increased lengths of stay (LOS) (4.5vs. 3.7days, P<.01) and increased rates of adverse events (41.7vs. 35.9%, P<.01), discharge to rehab (16.4vs. 8.6%, P<.01) and skilled nursing facilities (12.2vs. 9.7%, P=.02), and readmission (6.2vs. 4.5%, P=.05). Both groups experienced similar rates of death, pulmonary embolus, deep vein thrombosis, deep and superficial surgical site infection and reoperation P>.05 for all). Patients with CKD that underwent laminectomy and fusion had higher rates of transfusion (6.8vs. 20.4%, P=.05). Patients older than 70 that underwent laminectomy and fusion experienced high rates of urinary tract infection (6.4vs. 2.6%, P=.02). CONCLUSIONS Posterior cervical laminectomy and fusion patients were found to have increased LOS, readmissions, and complications despite having similar preoperative demographics and comorbidities. Patients and surgeons should consider these risks when considering surgical treatment for cervical pathology. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT A surgical invasiveness index exists for general spine surgery and adult spinal deformity, but a cervical deformity (CD) index has not been developed. PURPOSE The aim of this study was to develop a novel surgical invasiveness index for CD surgery that incorporates CD-specific parameters. STUDY DESIGN/SETTING Retrospective review of a multicenter prospective CD database. PATIENT SAMPLE Eighty-five CD patients with complete baseline demographic, clinical, and surgical details and 1-year data. OUTCOME MEASURES Cervical and global alignment parameters: cSVA, cervical lordosis, C2 slope, C2-T3 angle, C2-T3 SVA, TS-CL, PI-LL, PT, and SVA. METHODS CD was defined as at least one of the following: C2–C7 Cobb>10°, CL>10°, cSVA>4 cm, CBVA>25°. Consensus from experienced spine and neurosurgeons selected weightings for each variable that went into the invasiveness index. Linear regression was used to predict operative time, EBL, and length of stay using the newly developed CD-specific invasiveness index, controlling for age, sex, and Charlson Comorbidity Index score. Binary logistic regression predicted high operative time (>338 minutes), high EBL (>600 cc), or high length of stay (>5 days) based on the median values of operative time, EBL and length of stay. Significance was set at P<.05. RESULTS Eighty-five CD patients were included (61.35±10.7years, 65.9% female). The variables included in the newly developed CD invasiveness index with their corresponding weightings were: history of prior cervical surgery (3), ACDF (2 per level), corpectomy (4 per level), levels fused (1 per level), implants (1 per level), posterior decompression (2 per level), Smith–Peterson osteotomy (2 per level), three column osteotomy (8 per level), fusion to upper cervical spine (2), absolute change in TS-CL, cSVA, T4-T12 thoracic kyphosis and SVA from baseline to 1-year follow-up. The newly developed CD invasiveness index was a significant independent predictor of estimated blood loss (R2=0.132, P=.042). This CD-specific index was also a significant independent predictor of operative time (R2=0.171, P=.004). CD-specific invasiveness index strongly predicted a hospital length of stay greater than 5days (R2=0.310, P<.001), high blood loss (R2=0.170, P=.011), and extended operative time (R2=0.207, P=.031). CONCLUSIONS Extended length of stay, operative time, and high blood loss werestrongly predicted by the newly developed CD invasiveness index, incorporating surgical factors and radiographic parameters clinically relevant for patients undergoing cervical deformity corrective surgery. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Obesity is associated with acceleration of musculoskeletal degenerative diseases and functional impairment secondary to spinal disorders. Bariatric surgery is an increasingly common treatment for severe obesity, but can affect bone and mineral metabolism. The effect of bariatric surgery on degenerative spinal disorders is yet to be fully described. PURPOSE To analyze changes in bariatric patients risk for spinal degenerative diseases and spinal surgery. STUDY DESIGN/SETTING Retrospective analysis of the prospectively collected New York State Inpatient Database (NYSID) years (2004–2013). PATIENT SAMPLE A total of 8,176 bariatric patients and 146,252 morbidly obese patients (without bariatric surgery). OUTCOME MEASURES Incidence of spinal diagnoses and spinal procedures. METHODS NYSID collects over 100 clinical and nonclinical data elements on over 2 million hospital admissions per year: diagnoses, procedures, patient demographics (eg sex, age, race), charges, length of stay, and hospital characteristics (size, location, teaching status). Patient linkage codes allow identification of readmissions within the time-frame analyzed. The incidence of degenerative spinal diagnoses and spinal surgery for simple fusions (one or two levels, one approach), complex fusions (three or more levels, or multiple approaches), or decompression-only procedures for spinal disorders was queried using ICD-9 codes for morbidly obese patients (ICD-9 278.01) with and without a history of bariatric surgery. RESULTS A total of 18,176 patients were identified in the NYSID database with a history of bariatric surgery and 146,252 patients were identified as morbidly obese without a history of bariatric surgery. Bariatric surgery patients have a significantly higher rate of spinal diagnoses than morbidly obese patients without bariatric surgery (19.3% vs. 8.1%, P<.001). Bariatric patients were more likely to have a cervical, thoracic, or lumbar spinal diagnoses than nonbariatric obese patients (P<.001). The most common spinal diagnoses for bariatric patients are lumbar spinal stenosis (5.0%), cervical disc herniation (3.3%), lumbar disc degeneration (3.4%), lumbar spondylolisthesis (2.9%), lumbar spondylosis (1.9%), and cervical spondylosis with myelopathy (2.0%). Spine procedure rates are higher for bariatric patients than nonbariatric overall (25.6% vs. 2.3%, P<.001) and for fusions and decompressions (P<.001). Post bariatric surgery, patients overall had lower medical comorbidity burden than morbidly obese patients without history of bariatric surgery, including lower rates of diabetes, uncontrolled diabetes, congestive heart failure, and myocardial infarctions (P<.001). When controlling for age, gender, and comorbidities, these results persist, with bariatric surgery patients having higher rates of spinal diagnoses and procedures. The average time between bariatric surgery and spine surgery is 2.9 years, with 21% of bariatric surgery patients having spine surgery within 1 year of the bariatric procedure, 40% by 2 years, 70% by 4 years, and 95% by 7 years after bariatric surgery. CONCLUSIONS Morbidly obese patients who have undergone bariatric surgery have a dramatically increased incidence of spinal diagnoses and procedures, which translates into elevated rates of surgical intervention as compared to morbidly obese patients without bariatric surgery and this relationship persists when controlling for age, gender, and CCI. Further study is necessary to determine if there is a pathophysiological mechanism underlying this higher risk of spinal disease and intervention in bariatric patients. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Computer adaptive testing is becoming increasingly common in assessing patient outcomes. The Patient Reported Outcome Measurement Information System (PROMIS) instruments of Physical Function, Pain Intensity and Pain Interference have been shown to correlate with established patient outcome metrics, though this relationship has yet to be investigated for patients with thoracolumbar spinal pathologies. PURPOSE The aim of this study was to study the relationship between PROMIS and ODI scores in thoracolumbar patients. STUDY DESIGN/SETTING Retrospective review of single institution clinical data and patient-reported outcome measures. PATIENT SAMPLE A total of 208 spine patients with a thoracolumbar (TL) diagnosis. OUTCOME MEASURES Legacy metrics: Oswestry Disability Index (ODI), Patient Reported Outcome Measurement Information System (PROMIS). METHODS Inclusion was patients greater than 18 years of age with a diagnosis related to the thoracolumbar spine (most common diagnoses included spinal stenosis, disc herniation, low back pain, disc degeneration, spondylolysis). Bivariate correlations assessed the linear relationships between ODI and PROMIS scores (Physical Function, Pain Intensity, and Pain Interference). Correlation cutoffs were used to assess patients with high and low correlation between ODI and PROMIS domains. Linear regression predicted the relationship of ODI to PROMIS outcomes. Statistical significance was set at P<.05. RESULTS A total of 208 patients with a thoracolumbar diagnosis were included (age 58.39 ± 73.32 years, 49% female). ODI correlated with PROMIS Physical Function (r=−0.737, P<.001), PROMIS Pain Interference (r=0.790, P<.001), and PROMIS Pain Intensity (r=0.668, P<.001). ODI strongly predicted PROMIS scores for Physical Function (R2=0.54, P<.001), Pain Intensity (R2=0.45, P<.001) and most strongly Pain Interference (R2=0.62, P<.001), however there are substantial amount of variability in PROMIS scores that ODI cannot account for. The specific ODI questions about walking and social life had strong correlations with all three PROMIS domains and questions about sitting and sleeping had the weakest correlations across the three PROMIS domains. PROMIS Physical Function correlated strongest with the ODI questions about walking (r=−0.708), social life (r=−0.657), and lifting ability (r=−0.578) and worse with sitting (r=−0.326) and sleeping (r=−0.371). PROMIS Pain Intensity correlated most with ODI pain intensity (r=0.644), social life (r=0.603) and walking (r=0.543) and worse with sitting, standing, and sleeping. PROMIS Pain Interference most strongly correlated with social life (r=0.754), traveling (r=0.686) and walking (r=0.661) and weakest with lifting, sleeping and sitting. CONCLUSIONS There is a large amount of variability in PROMIS scores that ODI cannot account for. Certain ODI questions, such as walking, social life, and lifting ability correlate strongly with PROMIS while ODI questions such as sitting, standing and sleeping do not correlate well with PROMIS. Further work is required to assess these discrepancies and tease out the factors contributing to these differences. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Computer adaptive testing facilitates quicker administration of patient-relevant questions. The Patient Reported Outcome Measurement Information System (PROMIS) instruments of Physical Function, Pain Intensity and Pain Interference have been shown to correlate with established patient outcome metrics, though this relationship has yet to be investigated in relation to patient satisfaction. PURPOSE The aim of this study was to study the relationship between PROMIS and VAS scores and patient satisfaction in thoracolumbar patients. STUDY DESIGN/SETTING Retrospective review of single institution clinical data and patient-reported outcome measures. PATIENT SAMPLE A total of 208 spine patients with a thoracolumbar (TL) diagnosis. OUTCOME MEASURES ODI, Visual Analog Scale (VAS) for Back and Leg pain, Scoliosis Research Society 22 (SRS-22); Patient Reported Outcome Measurement Information System (PROMIS). METHODS Inclusion was patients greater than 18 years with a diagnosis related to the thoracolumbar spine (stenosis, disc herniation, low back pain, disc degeneration, spondylolysis most commonly). Bivariate correlations assessed the linear relationships of PROMIS scores (Physical Function, Pain Intensity, and Pain Interference) and ODI with VAS Leg and Back pain scores and patient satisfaction (SRS-22) questions specific to patient satisfaction of their back shape and back management. Linear regression predicted the relationship of PROMIS to VAS and satisfaction outcomes. Statistical significance was set at P<.05. RESULTS A total of 208 patients with a thoracolumbar diagnosis were included (age 58.39 ± 73.32 years, 49% female). VAS back pain scores (r=0.673, P<.001) correlated more strongly with PROMIS Pain Intensity than ODI (r=0.668, P<.001). ODI was more strongly correlated with the PROMIS Physical Function and Pain Interference domains, though VAS scores still significantly correlated (Physical Function r=−0.472, P<.001) and Pain Interference r=0.568, P<.001). ODI scores of TL patients predicted all PROMIS Physical Function and Pain Intensity better than VAS back pain, though VAS back pain predicted PROMIS Pain Intensity with the same predictability as ODI (both R2=0.45, P<.001). PROMIS Pain Intensity (R2=0.255, P<.001) predicted VAS Back Pain scores better than ODI (R2=0.242, P<.001), though ODI predicted VAS Back Pain more strongly than PROMIS Pain Interference (R2=0.216, P<.001) and Physical Function (R2=0.208, P<.001). Patients' satisfaction with their back shape in its current state correlated strongly with PROMIS scores in all three metrics (Physical Function: r=0.452; Pain Intensity: r=−0.438; Pain Interference: r=−0.522; all P<.001), with higher satisfaction correlating with better physical function and reduced pain. Satisfaction with back management was also significantly correlated with PROMIS scores (Physical Function: r=0.301; Pain Intensity: r=−0.331; Pain Interference: r=−0.410; all P<.001). CONCLUSIONS VAS Back Pain scores predicted PROMIS Pain Intensity scores as strongly as ODI, though ODI outperformed in predicting PROMIS Physical Function and Pain Interference. Conversely, PROMIS Pain Intensity predicted VAS Back Pain stronger than ODI, though ODI outperformed the other two PROMIS domains. Patients' satisfaction of the shape of their back and their back management were significantly correlated with PROMIS scores in all three domains. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Increased usage of computer adaptive testing such as Patient Reported Outcome Measurement Information System (PROMIS) aims to improve the capture of high quality patient outcomes. Recent work has shown correlations between PROMIS and the Oswestry Disability Index (ODI), but not specifically in a thoracolumbar population using the PROMIS Physical Function, Pain Intensity and Pain Interference computer adaptive domains. PURPOSE The aim of this study was to study the relationship between PROMIS and ODI scores in thoracolumbar patients. STUDY DESIGN/SETTING Retrospective review of single institution clinical data and patient-reported outcome measures. PATIENT SAMPLE A total of 208 spine patients with a thoracolumbar (TL) diagnosis. OUTCOME MEASURES Legacy metrics: Oswestry Disability Index (ODI), PROMIS. METHODS Inclusion was patients greater than 18years with a diagnosis related to the thoracolumbar spine (stenosis, disc herniation, low back pain, disc degeneration, spondylolysis most commonly). Bivariate correlations assessed the linear relationships between ODI and PROMIS scores (Physical Function, Pain Intensity and Pain Interference). Linear regression predicted the relationship of ODI to PROMIS outcomes. Statistical significance was set at P<.05. RESULTS A total of 208 patients with a thoracolumbar diagnosis were included (age 58.39±73.32years, 49% female). ODI strongly correlated with PROMIS Physical Function (r=−0.737, P<.001), PROMIS Pain Interference (r=0.790, P<.001), and PROMIS Pain Intensity (r=0.668, P<.001). Visual analog scale back is correlated with each of the three components of PROMIS assessed, most strongly with Pain Intensity (r=0.673, P<.001), though still did correlate with Physical Function (r=−0.472, P<.001) and Pain Interference (r=0.568, P<.001). ODI scores of TL patients strongly predicted PROMIS scores for Physical Function (R2=0.54, P<.001), Pain Intensity (R2=0.45, P<.001) and most strongly Pain Interference (R2=0.62, P<.001), and thus PROMIS domains predict ODI. CONCLUSIONS The well-established patient reported outcome ODI correlated strongly with PROMIS domains. ODI score strongly predicts PROMIS scores for all three components (Physical Function, Pain Intensity, Pain Interference) for thoracolumbar spine patients. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Regional and segmental changes of the lumbar spine have previously been described as patients transition from standing to sitting, however alignment changes in the cervical and thoracic spine have yet to be investigated. PURPOSE The aim of this study was to assess cervical and thoracic regional and segmental changes in patients with normal spinal pathologies. STUDY DESIGN/SETTING Retrospective review of a single center database of full-body stereoradiographic imaging and clinical data. PATIENT SAMPLE A total of 207 patients with nondegenerative, nondeformity spinal pathology. OUTCOME MEASURES Global alignment parameters: sagittal vertical axis (SVA), PI-LL, PT, TK. Cervical alignment: cSVA, C2–C7 lordosis (CL), T1 slope minus CL (TS-CL). Segmental changes in alignment from C2 to T12 between standing and sitting radiographs. METHODS Patients age >18years old with nondegenerative, nondeformity spinal pathologies. Patients with lumbar degenerative conditions or thoracolumbar deformity were excluded. Sub-analysis was performed of patients with cervical and thoracic segmental measurements. RESULTS A total of 207 patients were included (age 51±16years, BMI 26.7±6 kg/m2). As patients transitioned from standing to sitting, there was an increase in pelvic tilt of 12.2° (11.9°–24.2°), an increase in PI-LL by 22.8° (−7.1°–15.7°), and increase in SVA by 53.3 mm (−4.2 mm to 49.2 mm, all P<.001). In the cervical spine, there was an average 3.9° increase in C2–C7 cervical lordosis (6.2°–10.2°, P=.001) from standing to sitting, with a 5.9° increase in C2–T3 angle (2.9°–8.8°, P<.001) and 3.0mm increase in C2–T3 SVA (41.3 mm to 44.3 mm, P=.001). The thoracic spine experienced a decrease in thoracic kyphosis by 5.4° (−37.9° to −32.5°, all P<.001). Segmental changes were observed at C4–C5 (1.4°–2.3°, P=.023) and C5–C6 (1.8° to 2.5°, P=.026) to help maintain horizontal gaze when moving from standing to sitting position. There were no significant segmental changes in the cervicothoracic junction (C7–T1 change of 0.33°, P=.206) or upper thoracic spine (T1–T4). T4–T8 showed the most mobility from standing to sitting, primarily at T6–T7 (−3.1° to −2.7°, P=.003) and T7–T8 (−2.6° to −2.1°, P<.001). CONCLUSIONS In this cohort of nondegenerative and nondeformity spine patients, the greatest amount of regional changes occur for cervical lordosis, C2–T3 angle, TK, SVA, and PI-LL as patients transition from standing to sitting position in order to maintain global spinal alignment, with C4–C5 and C5–C6 having the greatest mobility. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Bariatric surgery is an increasingly common treatment for morbid obesity that has the potential to effect bone and mineral metabolism. The effect of prior bariatric surgery on outcomes following spinal surgery has not been well-established. PURPOSE To assess differences in complication rates following spinal surgery for patients with and without a history of bariatric surgery. STUDY DESIGN/SETTING Retrospective analysis of the prospectively collected New York State Inpatient Database (NYSID) years (2004–2013). PATIENT SAMPLE A total of 1,939 patients with prior bariatric surgery now undergoing spine surgery, 1,625 overweight or obese spine surgery patients (no bariatric procedures), and 28,304 spine surgery patients who are not obese or overweight. OUTCOME MEASURES Complications following spine surgery. METHODS Retrospective analysis of the prospectively collected New York State Inpatient Database (NYSID) years 2004-2013. Patient linkage codes allow identification of multiple and return inpatient stays within the time-frame analyzed. Complication rates were compared between bariatric surgery patients now undergoing spine surgery versus morbidly obese patients having spine surgery. Bariatric surgery (BS) patients and morbidly obese patients (non-BS) were divided into cervical and thoracolumbar surgical groups and were propensity score matched for age, gender and degree of invasiveness. Nonobese spine surgery patients were used as a standard. RESULTS A total of 1,939 spine surgery patients with a history of BS were compared to 1,625 non-BS spine surgery patients in the NYSID database. A total of 89% of normal weight spine surgery patients had a decompression and the overall complication rate for these patients is 45%. The average time from bariatric surgery to spine surgery is 2.95 years. BS patients had primarily two-three level fusions and decompressions, which is similar to non-BS patients. After propensity score matching for age, gender and invasiveness, 740 BS patients were compared to 740 non-BS patients undergoing thoracolumbar surgery, with similar comorbidity rates between cohorts. The overall complication rate for BS patients undergoing thoracolumbar surgery was significantly lower than non-BS patients (45.8% vs. 58.1%, P<.001). The most common complications following thoracolumbar surgery for BS patients were anemia (20.3%), bowel issues (12.3%), device-related complications (6.1%), and digestive problems (5.0%). BS patients undergoing a thoracolumbar procedure experienced lower rates of device-related complications (6.1% vs. 23.2%, P<.001), DVT (1.2% vs. 2.7%, P=.039), and hematomas (1.5% vs. 4.5%, P<.001) than non-BS patients undergoing thoracolumbar surgery. Neurologic complications were similar between BS patients and non-BS patients (2.3% vs. 2.7%, P=.62) and this rate was similar to normal weight patients undergoing spine procedures (1.65%). Spine surgery revision rates for BS patients was 14.9% and the average length of stay for BS patients undergoing spine surgery was higher than non-BS patients undergoing thoracolumbar surgery (5.95 days vs. 5.14 days, P=.007). For patients undergoing cervical spine surgery, BS patients experienced lower rates of bowel issues, device-related, and overall complication rates than non-BS patients (all P>.05). CONCLUSIONS Bariatric surgery patients undergoing spine surgery experience lower overall complication rates than morbidly obese patients. This study warrants further investigation into these populations to mitigate risks associated with spine surgery for bariatric patients. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT As the field of cervical deformity (CD) surgery has continued to progress, it is increasingly common for surgeons to operate on more challenging cases and higher risk patients, resulting in longer operative time and inpatient length of stay (LOS). The factors predicting extended operative time and LOS for CD patients have been understudied. PURPOSE Identify predictors of extended operative time and LOS after CD-corrective surgery using a statistical learning algorithm. STUDY DESIGN/SETTING Retrospective review of prospective, multicenter CD database. PATIENT SAMPLE A total of 142 surgical CD patients. OUTCOME MEASURES Operative time, LOS, health-related quality of life (HRQL) scores. METHODS Cervical deformity patients (C2–C7 Cobb>10°, CL>10°, cSVA>4cm, or CBVA>25°)>18 years with baseline (BL) radiographic data. Patients were stratified: extended LOS (E-LOS; >75th percentile) and normal LOS (N-LOS; <75th percentile). Op time analysis excluded staged cases and cases>12 hours. Univariate tests assessed differences in BL patient and surgical metrics between LOS groups and extended op time. Conditional Inference Decision Trees identified factors contributing to extended LOS and op time, and cut-offs at which factors have a global effect. A Conditional Variable Importance Table used a nonreplacement sampling set of 3,000 Conditional Inference trees to identify influential factors from patient and surgical data. Mean comparison tests compared LOS and op time for top factors at statistically meaningful cut-offs to determine effect size. RESULTS Included: a total of 142 patients (61±11 years, 62%F) undergoing surgery for CD (8.2±4.5 levels; 49.3% posterior approach, 15.4% anterior, 35.2% combined). Mean overall LOS and op time: 7.2±8.7 days and 358±213 minutes, respectively. 30% of patients experienced E-LOS (14±13 days); mean EBL was 796±863cc. There was no difference in LOS across enrolling surgical centers (P=.837), or age, sex, comorbidity burden, and BL HRQLs between LOS groups (all P>.05). Overlapping predictors of both E-LOS and op time included levels fused (>7 increased LOS 2.7 days; >5 increased op time 96 minutes, both p<.001), surgical approach(compared to posterior, anterior reduced LOS 3.0 days; combined increased op time 69 minutes, both p<.01), patient BMI (>38kg/m2 increased LOS 8.1 days; >39kg/m2 increased op time 17 minutes), and osteotomy (increased LOS 2.0 days, op time 62minutes, both p<.005). BL cervical parameters also contributed to increased LOS and op time: cSVA (>42mm increased LOS 2.1 days; >50mm increased op time 53 minutes, both p<.03), C0 slope (>−0.9° increased LOS 3.8 days, >0.3° increased op time 71 minutes, both p<.003). Additional op time predictors: prior cervical surgery (increased 62 minutes, p-.004) and presence of any comorbidity (increased 60 minutes, p=.015). Other predictors of E-LOS: blood loss (>850cc increased 4.2 days, P<.001), postop change in mental status (increased by 9.6 days, p=.001). Overall LOS was correlated with inferior 1 year HRQL scores: EQ-5D (r=−.199, P=.050) and mJOA (r=−.238, P=.024). Similarly, longer op time correlated with lower rates of reaching 1 year MCID for NDI (r=−0.253, p=.02) and mJOA (r=−0.302, p=.009). CONCLUSIONS Baseline cervical malalignment, levels fused, and osteotomy were all predictors of both increased operative time and inpatient length of stay. Increased LOS and operative time also correlated with inferior 1-year clinical outcomes. These results can be used in future efforts to optimize patient care, hospital efficiency, and resource allocation. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Hospital-acquired conditions (HACs) have significant deleterious effects on patients and providers. These events have been the focus of recent policy initiatives by the Centers for Medicare and Medicaid Services in an effort to improve patient safety and outcomes. PURPOSE To determine the rates of the three most common HACs that occur within 30-days postoperatively for spine surgeries and compare them to other common surgical procedures. STUDY DESIGN/SETTING Retrospective review of prospectively collected data. PATIENT SAMPLE A total of 647,878 patients from a national database undergoing common surgical procedures. OUTCOME MEASURES Rates of the three most common HACs: superficial or deep surgical site infection (SSI), venous thromboembolism (VTE), and urinary tract infection (UTI). These rates were compared between patients undergoing spine surgery versus other surgical procedures. METHODS Patients over 18 years who underwent elective spine surgery were identified in the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2013. These patients were stratified by whether they experienced at least one HAC and then compared to those undergoing other common procedures including bariatric surgery, hip and knee arthroplasty (THA and TKA, respectively). RESULTS A total of 90,551 elective spine surgery patients were identified in the NSQIP database, of which 3021 (3.3%) developed at least one HAC. SSI was the most common HAC (1.4%), followed by UTI (1.3%) and VTE (0.8%). Stratified by surgery type, fusion procedures were associated with higher rates of overall HACs compared to decompression-only procedures (1.0% vs. 0.5%, p<.001) as well as higher rates of each individual HAC (SSI, UTI, and VTE) (all p<.05). Rates of HACs in spine surgery were significantly higher than other elective procedures including bariatric surgery (2.8%) and THA (2.8%) (both p<.001). Spine patients also experienced higher rates of UTI and VTE compared to bariatric patients, though lower rates of SSI (1.4% vs. 1.7%, p<.001). Spine surgery and TKA patients had similar rates of HACs (3.3% vs. 3.4%, p=.287), though spine patients experienced higher rates of SSI (1.4% vs. 0.8%, p<.001) and UTI (1.3% vs. 1.1%, p<.001) but lower rates of VTE (0.8% vs. 1.6%, p<.001). Spine surgery patients had lower rates of HACs overall (3.3% vs. 5.9%) and for each of the three most common HACs compared to patients undergoing cardiothoracic surgery including valvular procedures and coronary artery bypass surgery (all p<.001. CONCLUSIONS Spine surgery patients experienced an overall HAC rate of 3.3%, with surgical site infections occurring most frequently. 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. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Background Previous studies have built a foundation for understanding compensation in patients with adult spinal deformity (ASD) by using full-body stereographic assessments. These mechanisms, in relation to age-adjusted alignment targets, have yet to be studied fully. The aim of this study was to assess lower-limb compensatory mechanisms of patients failing to meet age-adjusted alignment goals. Methods Patients with ASD ≥40 years with full body baseline and follow-up radiographs were included. Patients were stratified by age (40–65 years, >65 years) and spinopelvic correction. Lower-limb compensation parameters (pelvic shift, hip extension, knee flexion [KA], ankle flexion [AA], and global sagittal angle [GSA]) for patients who matched and failed to match age-adjusted alignment targets were compared with analysis of variance and t -test analysis. Results In total, 108 patients were included. At 1 year, AA increased with age in the “match” pelvic tilt (PT) and spinopelvic mismatch (PI-LL) cohorts (PT: AA, 5.6–7.8, P = 0.041; PI-LL: 4.9–8.8, P = 0.026). KA, AA, and GSA increased with age in the “match” sagittal vertical axis (SVA) cohort (KA: 3.8–13.1, P = 0.002; AA: 5.8–10.2, P = 0.008; GSA: 3.9–7.8, P < 0.001), as did KA and GSA in the “match” T1 pelvic angle group (KA: 1.8–8.7, P = 0.020; GSA: 2.6–5.7, P = 0.004). Conclusions Greater compensation captured by KA and GSA was associated with age progression in the “match” SVA and T1 pelvic angle cohorts. In addition, older SVA, PT, and PI-LL “match” cohorts used increased AA, suggesting that ideal postoperative alignment of aged individuals with ASD involves increased compensation. [ABSTRACT FROM AUTHOR]

We investigated the 30-day complication incidence and 1-year radiographic correction in obese patients undergoing surgical treatment of cervical deformity. The patients were stratified according to World Health Organization's definition for obesity: obese, patients with a body mass index of ≥30 kg/m2; and nonobese, patients with a body mass index of <30 kg/m2. The patients had undergone surgery for the treatment of cervical deformity. The patient baseline demographic, comorbidity, and radiographic data were compared between the 2 groups at baseline and 1 year postoperatively. The 30-day complication incidence was stratified according to complication severity (any, major, or minor), and type (cardiopulmonary, dysphagia, infection, neurological, and operative). Binary logistic regression models were used to assess the effect of obesity on developing those complications, with adjustment for patient age and levels fused. A total of 124 patients were included, 53 obese and 71 nonobese patients. The 2 groups had a similar T1 slope minus cervical lordosis (obese, 37.2° vs. nonobese, 36.9°; P = 0.932) and a similar C2–C7 (−5.9° vs. −7.3°; P = 0.718) and C2–C7 (50.1 mm vs. 44.1 mm; P = 0.184) sagittal vertical axis. At the 1-year follow-up examination, the T1 pelvic angle (1.0° vs. −3.1°; P = 0.021) and C2–S1 sagittal vertical axis (−5.9 mm vs. −35.0 mm; P = 0.036) were different, and the T1 spinopelvic inclination (−1.0° vs. −2.9°; P = 0.123) was similar. The obese patients had a greater risk of overall short-term complications (odds ratio, 2.5; 95% confidence interval, 1.1–6.1) and infectious complications (odds ratio, 5.0; 95% confidence interval, 1.0–25.6). Obese patients had a 5 times greater odds of developing infections after surgery for adult cervical deformity. Obese patients also showed significantly greater pelvic anteversion after cervical correction. [ABSTRACT FROM AUTHOR]

Background: Little is known of how frailty, a dynamic measure of physiological age, progresses relative to age or disability status. Operative treatment of adult spinal deformity (ASD) may play a role in frailty remediation and maintenance.Purpose: Compare frailty status, severe frailty development, and factors influencing severe frailty development among ASD patients undergoing operative or nonoperative treatment.Design: Retrospective review with maximum follow-up of 3 years.Setting: Prospective, multicenter, ASD database.Participants: Patients were consecutively enrolled from 13 participating centers.Inclusion Criteria: ≥18 years undergoing either operative or nonoperative treatment for ASD, exclusion criteria: spinal deformity of neuromuscular etiology, presence of active infection, or malignancy. The mean age of the participants analyzed were 54.9 for the operative cohort and 55.0 for the nonoperative cohort.Outcomes Measures: Frailty status, severe frailty development, and factors influencing severe frailty development.Methods: ASD patients (coronal scoliosis ≥20°, sagittal vertical axis (SVA) ≥5 cm, Pelvic Tilt (PT) ≥25°, or thoracic kyphosis ≥60°) >18 y/o, with Base Line (BL) frailty scores were included. Frailty was scored from 0 to 1 (not frail: <0.3, frail 0.3-0.5, severe frailty >0.5) through the use of ASD-frailty index (FI) which has been validated using the International Spine Study Group (ISSG) ASD database, European Spine Study Group ASD database, and the Scoli-RISK-1 Patient Database. The ISSG is funded through research grants from DePuy Synthes and individual donations and supported the current work. Operative (Op) and Nonoperative (Non-Op) patients were propensity matched. T-tests compared frailty among treatment groups and BL, 1, 2, and ≥3 years. An actuarial Kaplan-Meier survivorship analysis with log-rank (Mantel-Cox) test, adjusting for patients lost to follow-up, determined probability of severe frailty development. Multivariate Cox Regressions gauged the effect of sagittal malalignment, patient and surgical details on severe frailty development.Results: The analysis includes 472 patients (236 Op, 236 Non-Op) selected by propensity score matching from a cohort of 1,172. Demographics and comorbidities were similar between groups (p>.05). Op exhibited decreased frailty at all follow-up intervals compared with BL (BL: 0.22 vs Y1: 0.18; Y2: 0.16; Y3: 0.15, all p<.001). Non-Op displayed similar frailty from BL to 2Y follow up, and increased frailty at 3Y follow up (0.23 vs 0.25, p=.014). Compared with Non-Op, Op had lower frailty at 1Y (0.18 vs 0.24), 2Y (0.16 vs 0.23), and 3Y (0.15 vs 0.25; all p<.001). Cumulative probability of maintaining nonsevere frailty was (Op: 97.7%, Non-Op: 94.5%) at 1Y, (Op: 95.1%, Non-Op: 90.4%) at 2Y, and (Op: 95.1%, Non-Op: 89.1%) at ≥3Y, (p=.018). Among all patients, baseline depression (hazard ratio: 2.688[1.172-6.167], p=.020), Numeric Rating Scale (NRS) back pain scores (HR: 1.247[1.012-1.537], p=.039), and nonoperative treatment (HR: 2.785[1.167-6.659], p=.021) predicted severe frailty development with having a HR>1.0 and p value<.05. Among operative patients, 6-week postoperative residual SVA malalignment (SRS-Schwab SVA+modifier) (HR: 15.034[1.922-116.940], p=.010) predicted severe frailty development indicated by having a HR>1.0 and p value <.05.Conclusions: Non-Op patients were more likely to develop severe frailty, and at a quicker rate. Baseline depression, increased NRS back pain scores, nonoperative treatment, and postoperative sagittal malalignment at 6-week follow-up significantly predicted severe frailty development. Operative intervention and postoperative sagittal balance appear to play significant roles in frailty remediation and maintenance in ASD patients. Frailty is one factor, in a multifactorial conservation, that may be considered when determining operative or nonoperative values for ASD patients. Operating before the onset of severe frailty, may result in a lower complication risk and better long-term clinical outcomes. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Common indications for transforaminal lumbar interbody fusion (TLIF) include foraminal stenosis, degenerative disc disease and spondylolisthesis. Although minimally invasive surgical techniques (MIS) for TLIF have been shown to provide adequate postoperative sagittal alignment, it is unclear whether these procedures result in adequate reduction of canal compressive forces. PURPOSE Assess baseline to postoperative changes in cross-sectional canal area in patients undergoing minimally invasive transforaminal lumbar interbody fusion. STUDY DESIGN/SETTING Retrospective clinical review of a prospective surgeon-maintained MIS database. PATIENT SAMPLE A total of 16 patients undergoing MIS TLIF. OUTCOME MEASURES Spinal canal cross-sectional area, stenotic levels. METHODS Consecutive patients >18years undergoing transforaminal lumbar interbody fusion via minimally invasive surgical technique were included. Patients with preoperative lumbar MRIs and postoperative lumbar MRI or CT scans were assessed for spinal canal cross sectional area at operative interspace levels. Stenotic levels were defined as canal cross sectional area <130 mm2, as previously published. All measurements were conducted using dedicated imaging software. Baseline to postoperative changes in canal cross sectional area was assessed using parametric and nonparametric means comparison tests, as appropriate. Significance was set to p<.05. RESULTS Overall, 16 patients met inclusion criteria and underwent minimally invasive transforaminal lumbar interbody fusion. Mean patient age was 54.3±12.1years, 63% of patients were female, and mean Charlson Comorbidity Index score was 0.86±1.10. Patients presented with three primary diagnoses: herniated nucleus pulposis (36.8%), stenosis (42.1%) and spondylosis (21.1%). On average, patients underwent fusions spanning 1.69±1.13 levels, and 37.5% of patients underwent multilevel fusion. 93.7% of cases involved laminotomy, 31.3% laminectomy, 81.3% foraminotomy. Mean operative time was 349 minutes and blood loss was 389±486 ccs. From baseline to postoperative intervals, 87.5% of patients showed an increase in mean operative interspace canal cross sectional area, with the overall cohort showing significant improvement in canal cross sectional area (207.6 mm2 to 301.6 mm2, p<.001). These changes corresponded with a decreased rate of postoperative stenosis, from 25.0% at baseline to 0.0% postoperative. While single-level and multilevel fusion patients all showed significant baseline to postoperative improvements in cross-sectional canal area (226 mm2 to 244 mm2, and 196 mm2 to 275 mm2, respectively, both p<.025), multilevel patients showed a greater pre- to postoperative change in canal cross-sectional area (118 mm2 vs. 79 mm2), although this difference did not reach statistical significance (p=.347). CONCLUSIONS Following minimally invasive transforaminal lumbar interbody fusion, patients showed a significant increase in spinal canal cross sectional area. This increase in canal cross sectional area corresponded with an overall decrease in the rate of lumbar stenosis, suggesting MIS TLIF procedures have the potential to provide adequate relief of spinal canal compressive forces. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Minimally invasive surgical (MIS) techniques for spinal fusion aim to reduce the morbidity and considerable soft-tissue damage associated with conventional open surgery. As longer, multilevel arthrodesis procedures are increasingly performed using MIS techniques, it is necessary to weigh the risks and benefits of multilevel MIS lumbar fusion as a function of fusion length. PURPOSE Investigate the relationship between number of levels fused and clinical outcomes in patients undergoing open and MIS lumbar fusion procedures. STUDY DESIGN/SETTING Retrospective clinical review at single institution. PATIENT SAMPLE A total of 437 patients undergoing lumbar interbody fusion by open or MIS technique. OUTCOME MEASURES Complication rates, length of stay (LOS), estimated blood loss (EBL) METHODS Patients undergoing <4 level lumbar interbody fusion were stratified by surgical technique (MIS or open), and subsequently grouped by fusion length: 1-level, 2-levels, 3+ levels. Hybrid cases were excluded. Patient demographics, Charlson Comorbidity Index (CCI) scores, surgical factors, and perioperative complication rates were compared between MIS and open cases at different fusion lengths using parametric and non-parametric means comparison tests, as appropriate. RESULTS Included: 437 patients (57±13 years, 51% F, 29.5 kg/m2) undergoing lumbar interbody fusion(1.6±0.9 levels fused, 72% involved transforaminal approach, 18% anterior, 14% lateral). Overall breakdown of fusion length groups was: 64% 1-level, 21% 2-level, 16% 3+ level. By surgical technique, 37.5% of cases were MIS and 62.5% were open. Patients undergoing open surgery were older (58 years vs. 55, p=.022) with more comorbidities(mean CCI: 1.5 vs. 0.9, p<.001) than MIS patients. Operative time did not differ between MIS and open patients at 1-level (MIS: 232 minutes vs. Open: 235, p=.684); however, MIS cases at 2-levels (322 minutes vs. 298) and 3+ levels (373 minutes vs. 343) were clinically, but not statistically, longer in duration (both p>.05). While periop complication rates were significantly lower for MIS patients at 1-level (16% vs. 29%, p=.012) and 2-levels (12% vs. 30%, p=.043), at 3+ levels, complication rates were comparable between MIS and open groups (38% vs. 36%, p=.921). Furthermore, despite no differences in rates of pulmonary and GI complications between MIS and open groups at 1-level and 2-levels (both p>.05), MIS patients undergoing 3+ level fusions had higher rates of ileus (13% vs. 0%, p=.003) and showed a trend of increased adverse pulmonary events (25% vs. 6%, p=.052). For all categories of fusion length, MIS procedures resulted in significantly less blood loss (all p<.01), corresponding with lower rates of anemia at 1-level (5% vs. 14%, p=.012) and 2-levels (3% vs. 16%, p=.055). At 3+ levels, however, anemia complication rates were similar between MIS and open patients (13% vs. 14%, p=.891). Inpatient LOS and ICU LOS were longer for open procedures at all fusion lengths (all p<.015). CONCLUSIONS As compared to corresponding open surgeries, minimally invasive lumbar interbody fusions provided diminishing clinical returns for multilevel procedures. While MIS patients had lower rates of perioperative complications for 1- and 2-level fusions, 3+ level MIS fusions resulted in overall complication rates comparable to those of open patients, and higher rates of adverse pulmonary and ileus events. These results can be used to improve counseling of patients indicated for multilevel lumbar interbody fusion. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Background Context: The postoperative recovery patterns of cervical deformity patients, thoracolumbar deformity patients, and patients with combined cervical and thoracolumbar deformities, all relative to one another, is not well understood. Clear objective benchmarks are needed to quantitatively define a "good" versus a "bad" postoperative recovery across multiple follow-up visits, varying deformity types, and guide expectations.Purpose: To objectively define and compare the complete 2-year postoperative recovery process among operative cervical only, thoracolumbar only, and combined deformity patients using area-under-the-curve (AUC) methodology.Study Design/setting: Retrospective review of 2 prospective, multicenter adult cervical and spinal deformity databases.Patient Sample: One hundred seventy spinal deformity patients.Outcome Measures: Common health-related quality of life (HRQOL) assessments across both databases included the EuroQol 5-Dimension Questionnaire and Numeric Rating Scale (NRS) back pain assessment. In order to compare disability improvements, the Neck Disability Index (NDI) and the Oswestry Disability Index (ODI) were merged into one outcome variable, the ODI-NDI. Both assessments are gauged on the same scale, with minimal question deviation. Sagittal Radiographic Alignment was also assessed at pre- and all postoperative time points.Methods: Operative deformity patients >18 years old with baseline (BL) to 2-year HRQOLs were included. Patients were stratified by cervical only (C), thoracolumbar only (T), and combined deformities (CT). HRQOL and radiographic outcomes were compared within and between deformity groups. AUC normalization generated normalized HRQOL scores at BL and all follow-up intervals (6 weeks, 3 months, 1 year, and 2 year). Normalized scores were plotted against follow-up time interval. AUC was calculated for each follow-up interval, and total area was divided by cumulative follow-up length, determining overall, time-adjusted HRQOL recovery (Integrated Health State, IHS). Multiple linear regression models determined significant predictors of HRQOL discrepancies among deformity groups.Results: One hundred seventy patients were included (27 C, 27 T, and 116 CT). Age, BMI, sex, smoking status, osteoporosis, depression, and BL HRQOL scores were similar among groups (p >. 05). T and CT patients had higher comorbidity severities (CCI: C 0.696, T 1.815, CT 1.699, p = .020). Posterior surgical approaches were most common (62.9%) followed by combined (28.8%) and anterior (6.5%). Standard HRQOL analysis found no significant differences among groups until 1-year follow-up, where C patients exhibited comparatively greater NRS back pain (4.88 vs. 3.65 vs. 3.28, p = .028). NRS Back pain differences between groups subsided by 2-years (p>.05). Despite C patients exhibiting significantly faster ODI-NDI minimal clinically important difference (MCID) achievement (33.3% vs. 0% vs. 23.0%, p < .001), all deformity groups exhibited similar ODI-NDI MCID achievement by 2-years (51.9% vs. 59.3% vs. 62.9%, p = 0.563). After HRQOL normalization, similar results were observed relative to the standard analysis (1-year NRS Back: C 1.17 vs. T 0.50 vs. CT 0.51, p < .001; 2-year NRS Back: 1.20 vs. 0.51 vs. 0.69, p = .060). C patients exhibited a worse NRS back normalized IHS (C 1.18 vs. T 0.58 vs. CT 0.63, p = .004), indicating C patients were in a greater state of postoperative back pain for a longer amount of time. Linear regression models determined postoperative distal junctional kyphosis (adjusted beta: 0.207, p = .039) and osteoporosis (adjusted beta: 0.269, p = .007) as the strongest predictors of a poor NRS back IHS (model summary: R2 = 0.177, p = .039).Conclusions: Despite C patients exhibiting a quicker rate of MCID disability (ODI-NDI) improvement, they exhibited a poorer overall recovery of back pain with worse NRS back scores compared with BL status and other deformity groups. Postoperative distal junctional kyphosis and osteoporosis were identified as primary drivers of a poor postoperative NRS back IHS. Utilization of the IHS, a single number adjusting for all postoperative HRQOL visits, in conjunction with predictive modelling may pose as an improved method of gauging the effect of surgical details and complications on a patient's entire recovery process. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT A T1 Slope minus cervical lordosis (TS-CL) angle of 20° has been described in the literature as a significant cutoff to define cervical deformity, however recent studies suggest that this cutoff needs to be redefined. PURPOSE The aim of this study was to develop a novel TS-CL threshold indicative of moderate to severe cervical disability. STUDY DESIGN/SETTING Single-center retrospective review. PATIENT SAMPLE A total of 69 cervical patients indicated for surgical treatment were included. OUTCOME MEASURES T1 slope minus cervical lordosis, neck disability index (NDI). METHODS Patients age 18years old with a primary cervical diagnosis indicated for surgical treatment were included. Patients with active infection, tumors or trauma were excluded. We tested possible cutoffs for TS-CL against the percentage of individuals meeting normative, mild, moderate (>25) and severe (>35) NDI scores at baseline. The TS-CL cutoff with the highest sensitivity to predict a normative, mild, moderate (>25) and severe (>35) NDI score was selected. RESULTS A total of 69 cervical patients indicated for surgical treatment were included (mean age 55.4±9.9years, 45% female, mean BMI 29.1±6.6 kg/m2). The average baseline NDI score was 39.9±20.9 for this cohort. At baseline, average TS-CL was 27.3°±18.8°, CL was 1.7°±17.6°, cSVA was 28.3 mm±17.3 mm. Spino-pelvic alignment parameters at baseline were as follows: PT 16.1°±8.3°, PI-LL −2.8°±11.9°, TK 38.8°±12.7° and SVA −6.3 mm±51.8 mm. Using previously established TS-CL severity breakdowns, 13 (18.8%) patients had mild TS-CL (<15°), 11 (15.9%) moderate TS-CL (15°–20°), and 45 (65.2%) had severe TS-CL (>20°). Using this cutoff of 20° as severe TS-CL, it did not correlate with NDI score (P=.390). After testing possible cutoffs of TS-CL that relate to moderate to severe NDI scores, a novel cutoff of 30.65° for TS-CL was related to an NDI score of ³25 points. CONCLUSIONS In a cohort of cervical surgery patients, a novel cutoff of 30.65°for TS-CL was predictive of moderate to severe neck disability, as described as an NDI score greater than or equal to 25 points. This criterion can be applied to cervical spine patients to better assess cervical disability. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Recent studies show similar clinical outcomes between primary and revision lumbar interbody fusion procedures performed using conventional open techniques. As an increasing number of lumbar fusions are performed using minimally invasive surgical (MIS) techniques, it is important to assess the corresponding complication risks between primary and revision lumbar interbody fusion procedures. PURPOSE Assess differences in perioperative outcomes between primary and revision MIS lumbar interbody fusion patients, and compare to those of patients undergoing corresponding procedures utilizing an open technique. STUDY DESIGN/SETTING Retrospective chart review at single academic institution. PATIENT SAMPLE A total of 154 lumbar interbody fusion patients (77 primary, 77 revision; 44 MIS, 110 open). OUTCOME MEASURES Perioperative complications, length of stay (LOS), estimated blood loss (EBL) METHODS Patients >18 years undergoing primary and revision lumbar interbody fusion were propensity score matched (PSM) for comorbidities and levels fused. Cases were grouped by surgical technique: MIS or open. demographics, charlson comorbidity index (CCI) scores, surgical factors, and perioperative complications incidences were compared between primary and revision cases using means comparison tests, as appropriate. Significance was set to p<.05. RESULTS Included: 154 lumbar interbody fusion patients (62±12 year, 62%F, 29±6 kg/m2). Fourty-four (29%) cases were MIS, and 110 (71%) were open. Proportion of revision cases within the MIS and open groups were 40.9% and 53.6%, respectively. Within both MIS and open groups, there were no differences between primary and revision cases in age, sex, BMI, CCI, or levels fused (all p>.05). For both MIS and open patients, there were no differences between primary and revision cases in surgical approach, rates of laminectomy, or number of interbodies (all p>.05). For both MIS and open techniques, primary and revision patients did not differ in EBL, op time, LOS, or ICU LOS (all p>.05). Similarly, within both MIS and open groups, there were no differences between primary and revision surgeries in overall rates of postop complications, including cardiac, pulmonary, urinary, infection, and anemia complications (all p>.05). Primary MIS cases had higher rates of intraoperative complications as compared to revision cases (19% vs. 0.0%, p=.048), unlike open procedures, in which primary cases had lower intraoperative complication rates (0% vs. 7%, p=.058). Whereas MIS and open groups did not differ in operative time of primary surgery (279 minutes vs. 280, p=.976), MIS revision procedures were shorter than open (244 minutes vs. 296, p=.024). For both primary and revision procedures, there were no differences between MIS and open groups in overall rates of postoperative complications(all p>.05); however, primary MIS cases had higher intraoperative complication rates than primary open cases (19% vs. 0%, p=.001). CONCLUSIONS Clinical outcomes of revision MIS lumbar interbody fusion were similar to those of primary surgery, with no differences in operative time, inpatient length of stay, blood loss, or rates of postoperative complications. Despite higher intraoperative complication rates for primary MIS fusions, postoperative clinical outcomes were similar between MIS and open groups for both primary and revision procedures. These results point to revision MIS lumbar interbody fusion as a comparable alternative to similar fusions preformed using conventional open techniques. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Currently, optimal timing of surgical intervention for traumatic cervical spinal cord injuries (SCIs), a life-altering event and enormous economic burden, is unclear. PURPOSE Our goal was to investigate the perioperative and postoperative outcomes in patients with traumatic SCIs. STUDY DESIGN/SETTING Retrospective review. PATIENT SAMPLE A total of 28,414 SCI patients. OUTCOME MEASURES Perioperative complications, mortality, length of stay, total hospital charges, discharge disposition. METHODS HCUP's NIS was queried for ICD-9 codes pertaining to cervical SCI w/ fracture (806-806.19). Patients without traumatic etiology, neuromuscular conditions (eg, Down syndrome), with SCIWORA, and without complete time to procedure (TTP) data were excluded. Patients were stratified into 7 groups by TTP: same-day as admission (SD), 1-day delay (1D), 2-day delay (2D), 3-day delay (3D), 4-7 days delay (4-7D), 8-14 days delay (8-14D), >14 days delay (>14D). In an attempt to reduce covariate bias, groups were propensity score matched (PSM) by age, comorbidity index (CCI), mechanism of injury (MOI) (fall, MVA, pedestrian), trauma status at admission (hypotension, shock, hemorrhage, intubation), and concurrent injuries. Surgical details, perioperative complications, length of stay, total charges, and discharge disposition was compared. Binary logistic regressions determined independent predictors of varying complications (reference: same-day). RESULTS A total of 28,414 patients were included. After PSM, 6,636 patients remained (948 per group). Overall age 49.3, gender: 25.4%F, 67.4% white, 15.1% black, 11.4% hispanic, CCI: 1.2. Most common MOIs were 38.2% MVAs, 32% falls, 19.9% pedestrian accidents, 5.7% assaults, 4.2% sports. Procedure rates were 64.2% spinal fusion (36.8% 2-3 lvls, 16.1% 4-8 lvls, 1.4% >8 lvls), 32.5% decompressions, 14.7% halo/traction. SD was associated with the highest mortality (28.8% vs. 6.1-11.6%), lowest LOS (15.14 vs. 15.24-54.2days) and total hospital charges ($172,086.93 vs. $204,931.12-$545,797.14), all p<.001. Relative to SD, all delay groups had significantly increased odds of postoperative respiratory complications (1D-OR: 2.8[1.5-5.1] à 8-14D-OR: 5.9[3.4-10.3]), infection (1D-OR: 1.2[0.3-4.1] à >14D-OR: 10.2[3.9-26.7]), discharging to another care facility (1D-OR: 3.0[2.1-4.3] à 8-14D-OR: 3.1[2.2-4.3]), or discharging with quadriplegia (1D-OR: 1.1[0.8-1.4] à >14D-OR: 1.5[1.2-1.9], exception 3D-OR: 0.9[0.6-1.1]). 2D and 3D were significantly less likely to develop ARDS (OR: 0.8[0.6-1.0], OR: 0.9[0.7-1.1]) and any complication (OR: 0.9[0.8-1.1], OR: 0.7[0.6-0.9]), while all delay groups were less likely to develop sepsis (ORs: 0.6-0.9, exception >14D OR: 2.3[1.7-3.1]) and paraplegia (ORs 0.0-0.8) compared to SD. CONCLUSIONS Patients operated on the same day as admission were significantly less likely to develop infection, respiratory complications, or discharge to another care facility. Same-day operative patients were also less likely to discharge with quadriplegia, and more likely to discharge with paraplegia, indicating early intervention may significantly benefit discharge neurologic status. 2-day and 3-day operative patients exhibited significantly less risk of developing ARDS, and complication, or sepsis. While immediate and 2-3 day delayed operations appear to have unique advantages, patients who underwent procedures >14 days after admission were associated with poor outcomes and discharge disposition. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Background Context: Distal junctional kyphosis (DJK) is a primary concern of surgeons correcting cervical deformity. Identifying patients and procedures at higher risk of developing this condition is paramount in improving patient selection and care.Purpose: The present study aimed to develop a risk index for DJK development in the first year after surgery.Study Design/setting: This is a retrospective review of a prospective multicenter cervical deformity database.Patient Sample: Patients over the age of 18 meeting one of the following deformities were included in the study: cervical kyphosis (C2-7 Cobb angle>10°), cervical scoliosis (coronal Cobb angle>10°), positive cervical sagittal imbalance (C2-C7 sagittal vertical axis (SVA)>4 cm or T1-C6>10°), or horizontal gaze impairment (chin-brow vertical angle>25°).Outcome Measures: Development of DJK at any time before 1 year.Methods: Distal junctional kyphosis was defined by both clinical diagnosis (by enrolling surgeon) and post hoc identification of development of an angle<-10° from the end of fusion construct to the second distal vertebra, as well as a change in this angle by <-10° from baseline. Conditional Inference Decision Trees were used to identify factors predictive of DJK incidence and the cut-off points at which they have an effect. A conditional Variable-Importance table was constructed based on a non-replacement sampling set of 2,000 Conditional Inference Trees. Twelve influencing factors were found; binary logistic regression for each variable at significant cutoffs indicated their effect size.Results: Statistical analysis included 101 surgical patients (average age: 60.1 years, 58.3% female, body mass index: 30.2) undergoing long cervical deformity correction (mean levels fused: 7.1, osteotomy used: 49.5%, approach: 46.5% posterior, 17.8% anterior, 35.7% combined). In 2 years after surgery, 6% of patients were diagnosed with clinical DJK; however, 23.8% of patients met radiographic definition for DJK. Patients with neurologic symptoms were at risk of DJK (odds ratio [OR]: 3.71, confidence interval [CI]: 0.11-0.63). However, no significant relationship was found between osteoporosis, age, and ambulatory status with DJK incidence. Baseline radiographic malalignments were the most numerous and strong predictors for DJK: (1) C2-T1 tilt>5.33 (OR: 6.94, CI: 2.99-16.14); (2) kyphosis<-50.6° (OR: 5.89, CI: 0.07-0.43); (3) C2-C7 lordosis<-12° (OR: 5.7, CI: 0.08-0.41); (4) T1 slope minus cervical lordosis>36.4 (OR: 5.6, CI: 2.28-13.57); (5) C2-C7 SVA>56.3° (OR: 5.4, CI: 2.20-13.23); and (6) C4_Tilt>56.7 (OR: 5.0, CI: 1.90-13.1). Clinically, combined approaches (OR: 2.67, CI: 1.21-5.89) and usage of Smith-Petersen osteotomy (OR: 2.55, CI: 1.02-6.34) were the most important predictors of DJK.Conclusions: In a surgical cohort of patients with cervical deformity, we found a 23.8% incidence of DJK. Different procedures and patient malalignment predicted incidence of DJK up to 1 year. Preoperative T1 slope-cervical lordosis, cervical kyphosis, SVA, and cervical lordosis all strongly predicted DJK at specific cut-off points. Knowledge of these factors will potentially help direct future study and strategy aimed at minimizing this potentially dramatic occurrence. [ABSTRACT FROM AUTHOR]

Background Context: With advances in the understanding of adult spinal deformity (ASD), more complex osteotomy and fusion techniques are being implemented with increasing frequency. Patients undergoing ASD corrections infrequently require extended acute care, longer inpatient stays, and are discharged to supervised care. Given the necessity of value-based health care, identification of clinical indicators of adverse discharge disposition in ASD surgeries is paramount.Purpose: Using the nationwide and surgeon-created databases, the present study aimed to identify predictors of adverse discharge disposition after ASD surgeries and view the corresponding differences in charges.Study Design/setting: This is a retrospective analysis of patients on the National Surgical Quality Improvement Program (NSQIP) database and of cost data from Medicare PearlDiver Database.Patient Sample: Patients undergoing thoracolumbar surgery for correction of ASD were included in the study.Outcome Measures: Primary analysis was performed to compare patients discharged to home with patients who either expired or were discharged to locations other than home. Secondary analysis was performed to determine the cost differences across discharge groups.Methods: Patients on NSQIP undergoing thoracolumbar ASD-corrective surgery with a primary diagnosis of scoliosis (ICD-9 code 737.x) and over the age of 18 were isolated. Predictors (demographic, clinical, and complications) of not-home (NH; rehab or skilled nursing facility) discharge were analyzed using binary logistic regression controlling for levels fused, decompressions, osteotomies, and revisions. Average 30- and 90-day costs of care were reported in home, rehab, and skilled nursing facility discharge groups in patients undergoing 8+ level thoracolumbar fusion.Results: A total of 1,978 patients undergoing lumbar ASD-corrective surgery were included for analysis (average age: 59.3 years, sex: 64% female). Average length of stay was 6.58 days. On multivariate regression analysis, age over 60 years (odds ratio [OR]: 0.28, confidence interval [CI]: 0.22-0.34) and female sex (p=.003) were independent predictors of adverse discharge status. Partially dependent preoperational functional status, defined as reliance on another person to complete some activities of daily living, increased likelihood of adverse discharge disposition (OR: 0.57, CI: 0.35-0.90). Despite controlling for all clinical variables except for the ones specific to each analysis, Smith-Petersen osteotomy (OR: 0.51, CI: 0.40-0.64), interbody device placement (OR: 0.80, CI: 0.64-0.98), and fixation to the iliac (OR: 0.54, CI: 0.41-0.70) increased the likelihood of adverse discharge. Complications most associated with adverse discharge were urinary tract infections (OR: 0.34, CI: 0.21-0.57) and blood transfusions (OR: 0.42, CI: 0.34-0.52). Relative to home discharge, 30-day costs of care were +$21,061 more expensive in rehab discharges, but not different in skilled nursing facility discharges (+$5,791, p=.177). The 90-day costs of care were $23,815 in rehab discharges (p<.001), but again not different from skilled nursing facility discharges (+$6,091, p=.212).Conclusions: Discharge destination to rehabilitation has a significant impact on the cost of thoracolumbar ASD surgeries. Patient selection can predict patients at higher risk of discharges to rehab or skilled nursing facility. [ABSTRACT FROM AUTHOR]

Background Context: Obesity as a comorbidity in spine pathology may increase the risk of complications following surgical treatment. The body mass index (BMI) threshold at which obesity becomes clinically relevant, and the exact nature of that effect, remains poorly understood.Purpose: Identify the BMI that independently predicts risk of postoperative complications following lumbar spine surgery.Study Design/setting: Retrospective review of the National Surgery Quality Improvement Program (NSQIP) years 2011-2013.Patient Sample: A total of 31,763 patients were undergoing arthrodesis, discectomy, laminectomy, laminoplasty, corpectomy, or osteotomy of the lumbar spine.Outcome Measures: Complication rates.Methods: The patient sample was categorized preoperatively by BMI according to the World Health Organization stratification: underweight (BMI <18.5), normal overweight (BMI 20.0-29.9), obesity class 1 (BMI 30.0-34.9), 2 (BMI 35.0-39.9), and 3 (BMI≥40). Patients were dichotomized based on their position above or below the 75th surgical invasiveness index (SII) percentile cutoff into low-SII and high-SII. Differences in complication rates in BMI groups were analyzed by Bonferroni analysis of variance (ANOVA) method. Multivariate binary logistic regression evaluated relationship between BMI and complication categories in all patients and in high-SII and low-SII surgeries.Results: Controlling for baseline difference in SII, Charlson Comorbidity Index (CCI) score, diabetes, hypertension, and smoking, complications significantly increased at a BMI of 35 kg/m2. The odds ratios for any complication (odds ratio [OR] [95% confidence interval {CI}]; obesity 2: 1.218 [1.020-1.455]; obesity 3: 1.742 [1.439-2.110]), infection (obesity 2: 1.335 [1.110-1.605]; obesity 3: 1.685 [1.372-2.069]), and surgical complication (obesity 2: 1.622 [1.250-2.104]; obesity 3: 2.798 [2.154-3.634]) were significantly higher in obesity classes 2 and 3 relative to the normal-overweight cohort (all p<.05).Conclusion: There is a significant increase in complications, specifically infection and surgical complications, in patients with BMI≥35 following lumbar spine surgery, with that rate further increasing with BMI≥40. [ABSTRACT FROM AUTHOR]