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• Surgical site infections produce no long-term differences in quality of life. • Surgical site infections associated with roughly $21,000 cost increase per case. • Surgical site infections render lumbar decompression cost ineffective. Surgical site infections (SSI) following spine procedures are serious and costly complications that may reduce patient quality of life (QOL). Deep SSIs may also extend hospitalizations and require surgical debridement or antibiotic therapy, increasing costs to both patients and the healthcare system. Here we sought to evaluate the effect of deep SSI on care cost and QOL outcomes in patients undergoing posterior lumbar decompression and fusion. To do so we performed a retrospective study of patients undergoing lumbar decompression and fusion between 2008 and 2012. Patients experiencing postoperative deep SSI were matched to controls not experiencing a deep SSI. Included patients had prospectively-gathered QOL outcome measures collected preoperatively and at 6 months postoperatively. Health resource utilization was recorded from patient electronic medical records over the 6-month follow-up. Direct costs were estimated using Medicare national payment amounts. Indirect costs were based on missed work days and patient income. We found both cohorts experienced significant improvements in QOL scores following surgery, and there were no significant differences between the cohorts. The average total cost was significantly higher in the infected cohort compared to controls ($37,009 vs. $16,227; p < 0.0001). Compared to controls, patients experiencing deep SSI had greater costs in each of the following categories: hospitalizations (p < 0.01), office visits (p = 0.03), imaging (p < 0.01), and medications (p < 0.01). Among those experiencing deep SSI, there are significant increases in costs, with minimal long-term impact on QOL outcomes as compared with controls at the six-month follow-up. [ABSTRACT FROM AUTHOR]

We present a 15 year institutional analysis of the factors affecting progression free survival (PFS) and overall survival (OS) in patients undergoing attempted resection of adult intramedullary spinal cord ependymomas. Intramedullary spinal cord tumors are rare but important clinical entities, and ependymomas are the most commonly encountered intramedullary tumor. In total, 53 adult patients over the span of 15 years were analyzed for OS, PFS, and the effects of plane of dissection (POD) and gross total resection (GTR) on functional and long term outcomes. The mean age was 45 years and median follow-up was 54 months. The follow-up neurological outcome and modified McCormick scale were used to determine the functional outcome. Kaplan–Meier curves were used to calculate progression and survival. The overall ability to achieve GTR was significantly correlated to identification of an intraoperative POD ( p < 0.001). There was a trend towards increased PFS with the ability to achieve a GTR. There was no significant difference in the pre- and postoperative functional outcome scores. The ability to achieve a GTR is strongly correlated to the identification of a POD in ependymomas. There is a trend towards an increased probability of PFS in intramedullary spinal cord tumors when GTR is achieved. The resection of these tumors is likely to halt, but not reverse, neurological deterioration. [ABSTRACT FROM AUTHOR]

Background context There are often multiple surgical treatment options for a spinal pathology. In addition, there is a lack of data that define differences in surgical treatment among surgeons in the United States. Purpose To assess the surgical treatment patterns among neurologic and orthopedic spine surgeons in the United States for the treatment of one- and two-time recurrent lumbar disc herniation. Study design Electronic survey. Patient sample An electronic survey was delivered to 2,560 orthopedic and neurologic surgeons in the United States. Outcome measures The response data were analyzed to assess the differences among respondents over various demographic variables. The probability of disagreement is reported for various surgeon subgroups. Methods A survey of clinical and radiographic case scenarios that included a one- and two-time lumbar disc herniation was electronically delivered to 2,560 orthopedic and neurologic surgeons in the United States. The surgical treatment options were revision microdiscectomy, revision microdiscectomy with in situ fusion, revision microdiscectomy with posterolateral fusion using pedicle screws, revision microdiscectomy with posterior lumbar interbody fusion/transforaminal lumbar interbody fusion (PLIF/TLIF), anterior lumbar interbody fusion (ALIF) with percutaneous screws, ALIF with open posterior instrumentation, or none of these. Significance of p=.01 was used to account for multiple comparisons. Results Four hundred forty-five surgeons (18%) completed the survey. Surgeons in practice for 15+ years were more likely to select revision microdiscectomy compared with surgeons with fewer years in practice who were more likely to select revision microdiscectomy with PLIF/TLIF (p<.001). Similarly, those surgeons performing 200+ surgeries per year were more likely to select revision microdiscectomy with PLIF/TLIF than those performing fewer surgeries (p=.003). No significant differences were identified for region, specialty, fellowship training, or practice type. Overall, there was a 69% and 22% probability that two randomly selected spine surgeons would disagree on the surgical treatment of two- and one-time recurrent disc herniations, respectively. This probability of disagreement was consistent over multiple variables including geographic, practice type, fellowship training, and annual case volume. Conclusions Significant differences exist among US spine surgeons in the surgical treatment of recurrent lumbar disc herniations. It will become increasingly important to understand the underlying reasons for these differences and to define the most cost-effective surgical strategies for these common lumbar pathologies as the United States moves closer to a value-based health-care system. [ABSTRACT FROM AUTHOR]

The surgical management of primary and metastatic spine tumors is an essential treatment modality. Because the most spine tumors are metastatic, surgical management of spine tumors is often palliative. However, when indicated, decompression and stabilization can lead to improved quality of life. There are a variety of primary benign and malignant tumors that can involve the spine, and each has its own general management principles. For all tumor types, the diagnostic evaluation and staging of the tumor are essential to determine appropriate management. Surgical management, when indicated, is either palliative or curative, and the gold standard is en bloc spondylectomy. The upper thoracic spine represents a unique region with anatomical obstacles to adequate access, making complete surgical excision difficult. This region of the spine also has unique biomechanical considerations and requires instrumentation for stabilization. Because of the difficulty in accessing the upper thoracic spine, several different approaches have been developed and modified. The management of upper thoracic spine tumors will be presented here, including a case study involving a primary malignancy involving the T1 vertebral body. [Copyright &y& Elsevier]

Abstract: Background: In today''s health-care environment, operational efficiency is intrinsic to balancing the need for increased productivity driven by rising costs and potentially decreasing reimbursement. Other operational factors kept constant, decreasing the time for a procedure can be viewed as one marker for increased efficiency. Purpose: To prospectively evaluate the time and operating room efficiency differences between the two methods for intraoperative level localization. Stydy design: Prospective nonrandomized study. Patient sample: Prospective consecutive patients undergoing a single-level anterior cervical discectomy and fusion (ACDF) with plate and allograft. Outcomes measures: Time for performance and interpretation of intraoperative localization radiograph. Methods: This is a prospective nonrandomized study of patients treated consecutively with a single-level ACDF with allograft and plating. All the patients underwent a conventional approach to the cervical spine. After exposure, a spinal needle was placed in the exposed intervertebral disc and a radiography was performed. Either a conventional or a digital radiography was used in each case. Results: Eighteen patients were enrolled in this study. Ten patients underwent localization with conventional radiography, whereas eight patients underwent localization with digital imaging. The mean time for conventional radiography was 823 seconds (standard deviation [SD], 159), and for digital, it was 100 seconds (SD, 34; p<.001). Conclusions: Current technology provides options for level localization. Digital imaging provides equally accurate information as conventional radiography in a significantly reduced amount of time. Image quality, ease or archival, and manipulation provided by digital radiography are superior to those by provided fluoroscopy. Keeping operational factors constant, decreasing the time for a procedure, and increasing the efficiency of the environment may be viewed as a surrogate for improving the cost basis for a procedure. [Copyright &y& Elsevier]

Abstract: Background context: Allograft bone is commonly used in various spinal surgeries. The large amount of recalled allograft tissue, particularly in recent years, has increased concerns regarding the safety of allograft bone for spinal surgery. An analysis of allograft recall and its safety in spinal surgery has not been reported previously. Purpose: To determine 1) the number and types of allograft recall and the reasons for recall, 2) the types of disease transmission to spine patients, and 3) assess the safety of allograft bone in spinal surgery. Study design/setting: Retrospective review. Methods: A retrospective review of all Food and Drug Administration (FDA) data from 1994 to June 2007 was reviewed to determine the amount and types of recalled allograft tissue. The literature and data from the Center for Disease Control were reviewed to determine the number and types of disease transmissions from allograft bone that have occurred to spine surgery patients during the study period. Results: There were 59,476 musculoskeletal allograft tissue specimens recalled by FDA during the study period, which accounts for 96.5% of all allograft tissue recalled in the United States. Improper donor evaluation, contamination, and recipient infections are the main reasons for allograft recall. There has been one case of human immunodeficiency virus infection transmission to a spine surgery patient in 1988. This is the only reported case of viral transmission. There are no reports of bacterial disease transmission from the use of allograft bone to spine surgery patients. Conclusions: The precise number of allografts used in spine surgery annually and the precise incidence of disease transmission to spine surgery patients linked to the use of allograft tissue is unknown. Musculoskeletal allograft tissue accounts for the majority of recalled tissue by FDA. Despite the large number of allograft recalls in this country, there is only one documented case in the literature of disease transmission to a spine surgery patient. There appears to be no overt risk associated with the use of allograft bone in spine surgery. However, as discussed in this article, there are certain aspects regarding the use of allograft bone that should be considered. [Copyright &y& Elsevier]

Abstract: Background context: Multilevel fusions, the use of allograft bone, and smoking have been associated with an increased risk of nonunion after anterior cervical discectomy and fusion (ACDF) procedures. Pulsed electromagnetic field (PEMF) stimulation has been shown to increase arthrodesis rates after lumbar spine fusion surgery, but there are minimal data concerning the effect of PEMF stimulation on cervical spine fusion. Purpose: To determine the efficacy and safety of PEMF stimulation as an adjunct to arthrodesis after ACDF in patients with potential risk factors for nonunion. Study design: A randomized, controlled, prospective multicenter clinical trial. Patient sample: Three hundred and twenty-three patients with radiographic evidence (computed tomography-myelogram [CT-myelo] or magnetic resonance imaging [MRI]) of a compressed cervical nerve root and symptomatic radiculopathy appropriate to the compressed root that had failed to respond to nonoperative management were enrolled in the study. The patients were either smokers (more than one pack per day) and/or were undergoing multilevel fusions. All patients underwent ACDF using the Smith–Robinson technique. Allograft bone and an anterior cervical plate were used in all cases. Outcome measures: Measurements were obtained preoperatively and at each postoperative interval and included neurologic assessment, visual analog scale (VAS) scores for shoulder/arm pain at rest and with activity, SF-12 scores, the neck disability index (NDI), and radiographs (anteroposterior, lateral, and flexion–extension views). Two orthopedic surgeons not otherwise affiliated with the study and blinded to treatment group evaluated the radiographs, as did a blinded radiologist. Adverse events were reported by all patients throughout the study to determine device safety. Methods: Patients were randomly assigned to one of two groups: those receiving PEMF stimulation after surgery (PEMF group, 163 patients) and those not receiving PEMF stimulation (control group, 160 patients). Postoperative care was otherwise identical. Follow-up was carried out at 1, 2, 3, 6, and 12 months postoperatively. Results: The PEMF and control groups were comparable with regard to age, gender, race, past medical history, smoking status, and litigation status. Both groups were also comparable in terms of baseline diagnosis (herniated disc, spondylosis, or both) and number of levels operated (one, two, three, or four). At 6 months postoperatively, the PEMF group had a significantly higher fusion rate than the control group (83.6% vs. 68.6%, p=.0065). At 12 months after surgery, the stimulated group had a fusion rate of 92.8% compared with 86.7% for the control group (p=.1129). There were no significant differences between the PEMF and control groups with regard to VAS pain scores, NDI, or SF-12 scores at 6 or 12 months. No significant differences were found in the incidence of adverse events in the groups. Conclusions: This is the first randomized, controlled trial that analyzes the effects of PEMF stimulation on cervical spine fusion. PEMF stimulation significantly improved the fusion rate at 6 months postoperatively in patients undergoing ACDF with an allograft and an anterior cervical plate, the eligibility criteria being patients who were smokers or had undergone multilevel cervical fusion. At 12 months postoperatively, however, the fusion rate for PEMF patients was not significantly different from that of the control group. There were no differences in the incidence of adverse events in the two groups, indicating that the use of PEMF stimulation is safe in this clinical setting. [Copyright &y& Elsevier]

Abstract: Background context: Several methods to sterilize allograft bone exist, including gamma irradiation and freeze-drying, which can alter the mechanical properties of the graft. Efforts are under way to develop a method for processing osseous allograft that maintains structural integrity. Herein is presented one such method. Purpose: To analyze the mechanical properties, compared with nontreated controls, of a novel sterilization process for allograft cortical bone. Study design/setting: A controlled biomechanical evaluation of allograft bone under various types of loading after a novel sterilization treatment. Patient sample: Not applicable; basic science. Outcome measures: The load to failure was recorded for both the study and control groups, and statistical analysis of these results was performed. Significance level (α) and power (β) were set to 0.05 and 0.90, respectively. Single-factor analysis of variance (ANOVA) was used to detect significant differences between the treated and untreated groups. A post-experimental power analysis was performed for each of the response variables. Methods: Cortical tibia and femur samples from seven cadaveric donors (mean age 68.7 years) were treated with Biocleanse and compared with untreated samples with regard to density and strength. All samples were loaded to failure under diametral and biaxial compression, shear, and three-point bending. Results: Statistical analysis was done on the density and failure stress for all modes of loading. ANOVA did not indicate a significant (p>.05) effect of treatment on the density except for the axial and biaxial specimens (p<.05). ANOVA analysis of failure stress demonstrated no significant differences (p>.05) between cortical bone treated with Biocleanse and untreated specimens under all four types of mechanical loading. Post-experimental power analysis revealed power to be greater than 0.9 for each test. Conclusions: Sterilization of allograft bone with Biocleanse does not significantly alter the mechanical properties when compared with untreated samples. The effect of this sterilization process on the osteoconductive and osteoinductive properties of allograft bone must be determined. [Copyright &y& Elsevier]

COMMENTARY ON: Comer GC, Smith MW, Hurwitz EL, et al. Retrograde ejaculation after anterior lumbar interbody fusion with and without bone morphogenetic protein-2 augmentation: a 10-year cohort controlled study. Spine J 2012;12:881–90 (in this issue). [Copyright &y& Elsevier]

There is a paucity of evidence describing the price information that is publicly available to patients wishing to undergo neurosurgical procedures. We sought to investigate the public availability and usefulness of price estimates for non-emergent, elective neurosurgical interventions. Google was used to search for price information related to 15 procedures in 8 major U.S. health care markets. We recorded price information that was published for each procedure and took note of whether itemized prices, potential discounts, and cross-provider price comparisons were available. Online searches yielded 2356 websites, of which 228 (9.7%) offered geographically relevant price information for neurosurgical procedures. Although accounting for only 16.4% of total search results, price transparency websites provided most treatment price estimates (74.1% of all estimates), followed by clinical sites (19.3%), and other related sites (5.3%). The number of websites providing price information varied significantly by city and procedure. websites rarely divulged data sources, specified how prices were estimated, indicated how frequently price estimates were updated, offered itemized breakdowns of prices, or indicated whether price estimates encompassed the full spectrum of possible health care charges. Under 10% of websites queried yield geographically relevant price information for non-emergent neurosurgical imaging and operative procedures. Even when this information is publicly available, its usefulness to patients may be limited by various factors, including obscure data sources and methods, as well as sparse information on discounts and bundled price estimates. Inconsistent availability and clarity of price information likely impede patients' ability to discern expected costs of treatment and engage in cost-conscious, value-based neurosurgical decision-making. [ABSTRACT FROM AUTHOR]

Approximately 250,000 patients per year who are on anticoagulants must interrupt their regimen to undergo surgery or an invasive procedure that poses a high risk for blood loss. These patients must be properly managed in order to balance the prevention of thromboembolic events with excessive bleeding risk during surgery. Current guidelines for the timing of preoperative interruption and postoperative resumption of long-term anticoagulant therapy have been outlined but are based on methodologically weak observational studies and low quality data.The ambiguity of the existing data is reflected in the postoperative anticoagulant management of many spine surgeons. While some surgeons are willing to restart postoperative anticoagulants soon after surgery, others choose to wait for fear of bleeding complications. While spine surgery patients represent a unique cohort at high risk for bleeding complications, data exploring perioperative anticoagulation management for this population is lacking. To determine the postoperative day of anticoagulant resumption in spine surgery patients that minimizes thromboembolic complications. This was a retrospective cohort study of spine surgery patients within one hospital system. The study included 1,441 patients who stopped medical anticoagulation for a spine surgery between the years 2008 and 2018 and who resumed anticoagulation while inpatients postoperatively. The primary outcome measure was incidence of thromboembolic complication, defined as cerebrovascular accident (CVA), myocardial infarction (MI), pulmonary embolism (PE), or deep vein thrombosis (DVT). All patients undergoing fusion or decompression spinal surgery between the years 2008-2018 who were medically anticoagulated within 14 days prior to surgery and who resumed anticoagulation while inpatient were studied. Ten independent predictors of thromboembolic events were examined: postoperative day of anticoagulant resumption, age, sex, race, aspirin use, Charlson Comorbidity Index (CCI), fusion as a component of surgery, multilevel surgery, and length of stay. Multivariate logistic regression analysis was used to identify which predictors increased the odds of a thromboembolic event. Of the 1,441 patients studied, 418 (29%) were restarted on anticoagulation on postoperative day (POD) #1, another 603 (41%) were restarted on POD#2, and 420 (29%) were restarted on POD#3 or later. Patients restarted on POD#3 or greater had an increased risk of thromboembolic events (OR 1.63, p = 0.038, 95% CI = 1.02 - 2.6). Other risk factors for clotting events included black race (OR 1.96, p = 0.007, 95% CI = 1.19 - 3.2), CCI greater than 3 (CCI 3-4: OR 2.67, p =.006; CCI 5-6: OR 3.04, p =.003; CCI 7+: OR 3.53, p <.001), and length of stay (OR 1.06 for each additional day, p <.001). In our study of medically anticoagulated patients undergoing spine surgery, resumption of anticoagulants on POD#3 or greater increased the risk of thromboembolic complications. This finding further reinforces recent literature suggesting that a conservative approach when resuming anticoagulants after surgery can lead to serious complications. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

The goal of this study was to identify predictors of prolonged operative time (OT) in patients receiving posterior/transforaminal lumbar interbody fusion (P/TLIF) and examine the relationship between prolonged OT and perioperative outcomes in this population. The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients undergoing single-level P/TLIF (Common Procedural Terminology code) between 2012 and 2018. Multivariable linear regression models were constructed to identify factors independently associated with changes in OT and examine the relationship between prolonged OT and perioperative outcomes (overall complications, surgical complications, medical complications, 30-day readmission, 30-day reoperation, and length of stay). All models were adjusted for sociodemographic variables, comorbidities, and procedure-specific variables. Our cohort included 6260 patients. After adjusting for baseline covariates, age between 19 and 39 years increased OT by 15.14 minutes, male sex increased OT by 12.91 minutes, African American race increased OT by 17.82 minutes, other race increased OT by 18.13 minutes, obesity class III increased OT by 27.80 minutes, and the use of navigation increased OT by 10.83 minutes. Our multivariate logistic regression also found that after 2 hours, each additional hour of OT was associated with an increased risk of any complication (3–3.99 hours, odds ratio [OR], 1.68; 4–4.99 hours, OR, 2.33; and >5 hours, OR, 4.65). Incremental increases in OT were also associated with an increased risk of extended length of stay, readmission, and return to the operating room. The results of this study highlight several factors associated with prolonged OT and underscore its association with poorer perioperative outcomes. These data can be used to risk stratify patients before single-level P/TLIF. [ABSTRACT FROM AUTHOR]

Background Context: Preoperative TNF-AI use has been associated with increased rate of postoperative infections and complications in a variety of orthopedic procedures. However, the association between TNF-AI use and complications following spine surgery has not yet been studied.Purpose: The purpose of the present study was to assess the risk of reoperation in patients prescribed TNF-AI undergoing spinal fusion surgery.Study Design: This is a retrospective review.Patient Sample: A total of 427 patients who underwent spinal fusion surgery at a large healthcare system from 1/1/2009 to 12/31/2018.Outcome Measure: Reoperation within 1 year.Methods: We retrospectively reviewed the records of patients who underwent spinal fusion surgery at a large healthcare system from 1/1/2009 to 12/31/2018. There were three distinct cohorts of spine surgery patients under study: patients with TNF-AI use in 90 days before surgery, patients with non-TNF-AI DMARD medications use in the 90 days before surgery, and patients taking neither TNF-AI nor other DMARD medications in 90 days before surgery. The primary outcome of interest was reoperation for any reason within 1 year following surgery.Results: Our study included 90 TNF-AI, 90 DMARD, and 123 control patients. Reoperation up to 1-year postsurgery occurred in 19% (n=17) of the TNF-AI group, 11% (n=10) of the DMARD group, and 6% (n=7) of the control group. The reasons for reoperation for TNF-AI group were 47% (n=8) infection and 53% (n=9) other causes which included failure to fuse and adjacent segment disease. Reasons for reoperation at 1 year were 40% (n=4) infection and 60% (n=6) other causes for DMARD patients and 14% (n=1) infection with 86% (n=6) other causes for control patients. The cox-proportional hazard model of reoperation within 1 year indicated that the odds of reoperation were 3.1 (95% CI:1.4-7.0) and 2.2 (95% CI 0.96-5.3) times higher in the TNF-AI and DMARD groups, respectively, compared to the control group.Conclusions: Patients taking TNF-AIs before surgery were found to have a significantly higher rate of reoperation in the 1 year following surgery compared to controls. The higher rate of reoperation associated with TNF-AI use before spinal fusion surgery represents the potential for higher morbidity and costs for patient which is important to consider for both surgeon and patient in preoperative decision making. [ABSTRACT FROM AUTHOR]

Preoperative patient optimization is increasingly recognized as key to good surgical outcomes. Preoperative hyponatremia is a modifiable risk factor linked to poorer postoperative outcomes in other surgical fields. We provide the first investigation of the association of preoperative hyponatremia with morbidity and mortality in patients undergoing cervical spine surgery. We queried the National Surgical Quality Improvement Program registry for patients who underwent cervical spine fusion. Preoperative serum sodium levels were classified as normal (135–145 mEq/L) or hyponatremic (<135 mEq/L); hypernatremic patients were excluded from the analysis. Multivariable logistic analyses using a multiple imputations methodology were performed to determine significant predictors of major morbidity and mortality (MMM). We included 20,817 patients, of whom 5.2% were hyponatremic at presentation. Preoperative hyponatremia was a significant predictor of MMM (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.09–1.39), mortality (OR, 1.36; 95% CI, 1.03–1.77), major morbidity (OR, 1.24; 95% CI, 1.10–1.40), and odds of prolonged hospitalization (OR, 1.13; 95% CI, 1.04–1.23). Other significant predictors of MMM included age, undergoing an emergent versus nonemergent operation, having chronic obstructive pulmonary disease, having disseminated malignancy, being functionally dependent, presenting with sepsis or septic shock, and having an American Society of Anesthesiologists status of 3, 4, or 5. Similar results were seen in analyses using only complete cases and in sensitivity analyses. Using the National Surgical Quality Improvement Program database, hyponatremia is observed in approximately 1 in every 20 patients undergoing cervical spine fusion. More importantly, it is a predictor of mortality, major morbidity, and prolonged hospitalization. From a systems-level perspective, preoperative hyponatremia may therefore represent a point of intervention for preoperative patient optimization. [ABSTRACT FROM AUTHOR]

To evaluate the differences in surgical outcomes of patients with cervical spondylotic myelopathy with and without congenital cervical spinal stenosis (CCSS). Institutional review board approval was obtained to conduct a retrospective chart review of patients with cervical spondylotic myelopathy who underwent decompression and fusion surgeries from 2010–2016 at a single institution. CCSS was identified using the Torg-Pavlov ratio on lateral cervical radiographs. Pre- and postoperative outcome measures were assessed using the modified Japanese Orthopedic Association (mJOA) and the EuroQol 5-dimension questionnaire (EQ-5D). Of 208 patients, Torg-Pavlov ratio identified 85 patients with CCSS. There were no significant differences between the CCSS patient and control patient groups in EuroQol 5-dimension questionnaire and mJOA scores at all 4 designated time points in the study (preoperative, earliest postoperative, 6 month postoperative, and 1 year postoperative). Although not statistically significantly, there was a notable trend for patients with CCSS to be less likely to have mJOA-defined severe myelopathy at the postoperative (odds ratio [OR], 0.75; P = 0.38), 6 month postoperative (OR, 0.66; P = 0.20), and 1 year postoperative (OR, 0.64; P = 0.14) time points. Postoperatively, compared with non-CCSS patients, patients with congenital cervical stenosis reported equal quality of life for all markers. Our findings suggest that in patients with CCSS and relatively mild symptoms of myelopathy, equal consideration should be given for surgical intervention. The findings of this study warrant further large-scale, multi-institutional investigation to further understand the generalizability of these surgical outcome results. [ABSTRACT FROM AUTHOR]

More than 120,000 anterior cervical discectomy and fusions (ACDFs) are performed annually. Pseudarthrosis is a potential delayed adverse event that affects up to 33% of patients. The degree to which this adverse event affects both patient quality-of-life (QOL) outcomes and health care costs is poorly understood. Patients who underwent revision surgery for pseudarthrosis between 2007 and 2012 were identified and matched to controls not experiencing pseudarthrosis in a 1:2 fashion (case/control). Cases and controls were compared regarding total health care costs incurred in the year after the index ACDF and QOL outcomes on the following metrics: EuroQol Five-Dimensions Questionnaire, Patient Health Questionnaire–9, and Pain Disability Questionnaire. Of 738 patients who underwent ACDF, 11 underwent surgery for pseudarthrosis. No differences were noted between cases and controls regarding any of the matched variables. Patients in the pseudarthrosis cohort had poorer postoperative scores on the EuroQol Five-Dimensions Questionnaire mobility, usual activities, pain/discomfort, and quality-adjusted life-year dimensions. In addition, 64% of patients with pseudarthrosis had worsened quality-adjusted life-year scores compared with only 9% of controls (P < 0.01). Patients with pseudarthrosis also had poorer mental health (P < 0.01) and pain disability outcomes (P < 0.01) than did controls. Pseudarthrosis was associated with significant increases in direct costs, direct postoperative costs, and total costs (all P < 0.01). This is the first study to characterize the effect of surgical revision for pseudarthrosis on both QOL outcomes and care costs after ACDF. Patients requiring revision experienced significantly poorer QOL outcomes and higher care costs relative to controls. [ABSTRACT FROM AUTHOR]

Background Context: A spinal epidural abscess (SEA) is a serious condition that may be managed with antibiotics alone or with decompressive surgery combined with antibiotics.Purpose: The objectives of this study were to assess the clinical outcomes of SEA after surgical management and to identify the patient-level factors that are associated with outcomes following surgical decompression and removal of SEA.Study Design/setting: Retrospective chart review analysis.Patient Sample: An analysis of 154 consecutive patients who initially presented to a tertiary-care, academic medical center with SEA, and were subsequently treated with surgery between 2010 and 2015 was performed.Outcome Measures: Postoperative predischarge American Spinal Injury Association Impairment Scale (AIS) scores, 6-month follow-up encounter AIS scores, need for revision surgery, and mortality during SEA surgery were the primary outcomes.Physiological Measures: AIS scores.Method: Fisher's exact and Wilcoxon rank-sum tests were used to assess the associations between patient-level factors and surgical outcomes. Moreover, an interactive, predictive model for postoperative predischarge AIS score was developed using a proportional odds regression model. There was no funding secured for this study and there is no conflict of interest-associated biases.Results: One hundred fifty-four patients (mean age of 58 years) were treated using surgical decompression in addition to antibiotics. The majority of patients were Caucasian (81%) and male (61%). No intraoperative mortality was reported. A second SEA surgery was performed in 8% of patients. A comparison of the preoperative and postoperative predischarge AIS scores showed that 49% of patients maintained a score of E or improved, while 45% remained at their preoperative status and 6% worsened. Among a subset of patients (n=36; 23%) for whom a 6-month follow-up encounter occurred, 75% maintained an AIS score of E or improved, 19% remained at their preoperative status, and 6% worsened. Both the presence and longer duration of preoperative paresis was associated with an increased risk of remaining at the same AIS score or worsening at the predischarge encounter (both p< .001). A predictive model for predischarge AIS scores was developed based on several patient characteristics.Conclusions: Surgical decompression can contribute to improving or maintaining AIS scores in a high percentage of SEA patients. The presence and duration of preoperative paresis are prognostic for poorer outcomes and suggest that rapid surgical intervention before paresis develops may lead to improved postoperative outcomes. Our modeling tool enables an estimation of probabilities of patients' predischarge condition. [ABSTRACT FROM AUTHOR]

Background: Carotid artery injury and stroke secondary to prolonged retraction remains an extremely rare complication in anterior cervical discectomy and fusion (ACDF). However, multiple studies have demonstrated that carotid artery retraction during the surgical approach may alter the normal blood flow, leading to a significant reduction in the cross-sectional area of the vessel. Others have suggested that dislodgment of atherosclerotic plaques following manipulation of the carotid artery can be a potential risk for intracranial embolus and stroke.Purpose: We aimed to evaluate: (1) the incidence of postoperative stroke following ACDF and (2) incidence of other postoperative complications in a cohort of patients who had a diagnosis of carotid artery stenosis (CAS) versus those who did not.Patient Sample: This study utilized the Statewide Planning and Research Cooperative System database from January 1, 2009 to December 31, 2013. All patients who underwent (ACDF) and had a preoperative diagnosis of CAS were identified using the International Classification of Disease, ninth revision codes. Those who had a previous history of stroke were excluded. Patients who had CAS were propensity score matched to patients without history of CAS for demographics and Charlson/Deyo comorbidity scores.Outcome Measures: Incidence of postoperative stroke and other complications were compared between the cohorts. The threshold for statistical significance was set at a p<.05. This study received no funding. The authors report no conflict of interests relevant to this study.Results: There were 34,975 patients who underwent an ACDF in the study time period. After excluding those under the age of 18 and with history of previous stroke, there were 61 patients who had CAS that were compared with a propensity-matched cohort. The CAS cohort had a significantly higher incidence of postoperative stroke during their hospitalization (6.6% vs 0%, p<.042). The CAS cohort also had higher rates of acute renal failure (27.9% vs 4.9%, p = .01) and sepsis (18% vs 4.9%, p = .023). There were no stroke related deaths.Conclusions: Patients with CAS who underwent ACDF had a statistically significant greater incidence of developing a postoperative stroke. To the best of our knowledge, no previous study has evaluated the development of postoperative stroke in patients with CAS undergoing ACDF. Larger, multicenter studies are needed to estimate the true incidence of stroke in this specific patient population. However, our results may illustrate the importance of preoperative optimization, approach-selection, and postoperative stroke surveillance in patients with a history of CAS who undergoes ACDF. [ABSTRACT FROM AUTHOR]

Background Context: Routine use of magnetic resonance imaging (MRI) as a diagnostic tool in lumbar stenosis is becoming more prevalent due to the aging population. Currently, there is no clinical guideline to clarify the utility of repeat MRI in patients with lumbar stenosis, without instability, neurological deficits, or disc herniation.Purpose: To evaluate the utility of routine use of MRI as a diagnostic tool in lumbar stenosis, and to help formulate clinical guidelines on the appropriate use of preoperative imaging for lumbar stenosis.Study Design/setting: Retrospective radiographic analysis.Patient Sample: Retrospective chart review was performed to review patients with lumbar stenosis, who underwent lumbar decompression without fusion from 2011 to 2015 at a single institution.Outcome Measures: Previously established stenosis grading systems were used to measure and compare the initial and the subsequent repeat lumbar MRIs performed preoperatively. If patients were found to have a moderate or severe grade change, and if the surgical plan was altered due to such exacerbated radiographic findings, then their grade changes were considered clinically meaningful.Methods: We identified patients with lumbar stenosis without radiographic instability or neurological deficits, who had at least two preoperative lumbar MRIs performed and underwent decompressive surgeries. At each pathologic disc level, the absolute value of the change in grade for central and lateral recess stenosis, right foraminal stenosis, and left foraminal stenosis from the first preoperative MRI to the repeated MRI was calculated. These changed data were then used to calculate the mean and median changes in each of the three types of stenosis for each pathologic disc level. Identical calculations were carried out for the subsample of patients who only underwent discectomy or had a discectomy included as part of their surgery.Results: Among the 103 patients who met the inclusion criteria, 37 of those patients had more than one level surgically addressed, and a total of 161 lumbar levels were reviewed. Among the subset of patients that had any grade change, the majority of the grades only had a mild change of 1 (36 out of 42 patients, 85.7%, 95% confidence interval [CI]: 73.1%-94.1%); there was a moderate grade change of 2 in two patients (4.8%, CI: 0.8%-14.0%), and a severe change of 3 in one patient (2.4%, CI: 0.2%-10.1%). There were three patients with decreased grade change (7.1%, CI: 1.8%-17.5%). All clinically meaningful grade changes were from the subset of patients who had only discectomy or discectomy as part of the procedure. Lastly, both patients that had a clinically meaningful grade change had their MRIs performed at an interval of greater than 360 days.Conclusions: The radiographic evaluation of the utility of routinely repeated MRIs in lumbar stenosis without instability, neurological deficits, or disc herniations demonstrated that there were no significant changes found in the repeated MRI in the preoperative setting, especially if the MRIs were performed less than one year apart. The results of this present study can help to standardize the diagnostic evaluation of lumbar stenosis and to formulate clinical guidelines on the appropriate use of preoperative imaging for lumbar stenosis patients. [ABSTRACT FROM AUTHOR]

Background Context: Prior studies have shown that patient-reported allergies can be prognostic of poorer postoperative outcomes.Purpose: The objective of this study was to investigate the correlation between self-reported allergies and outcomes after cervical or lumbar spine surgery.Study Design/setting: This is a retrospective cohort study at a single tertiary care institution.Patient Sample: The patient sample included all patients undergoing cervical or lumbar spine surgery from 2009 to 2014.Outcome Measures: The primary outcome measure was change in the EuroQol-5 Dimensions (EQ-5D) after surgery. Secondary outcomes included changes in the Pain Disability Questionnaire (PDQ) and in the Patient Health Questionnaire-9 (PHQ-9), achievement of the minimal clinically important difference (MCID) in these measures, and cost of admission.Methods: Before and after surgery, EQ-5D, PDQ, and PHQ-9 were recorded for patients with available data. Paired Student t tests were used to compare changes in these measures after surgery. Multivariable linear and logistic regressions were used to assess the relationship between the log transformation of the total number of allergies and outcomes.Results: A total of 592 cervical patients and 4,465 lumbar patients were included. The median number of reported allergies was two. The EQ-5D index increased from 0.539 to 0.703 for cervical patients and from 0.530 to 0.676 for lumbar patients (p<.01 for both). Patients experienced significant pain improvement by the PDQ (80.1-58.2 for cervical patients and 79.4-58.1 for lumbar patients, p<.01). Using multivariable logistic regression, the log transformation of the number of allergies predicted significantly higher odds of achieving the PDQ MCID (odds ratio [OR]=2.09, 95% confidence interval [CI] 1.05-4.15, p=.02, for cervical patients; OR=1.30, 95% CI 1.03-1.68, p=.03, for lumbar patients). However, this relationship was not durable for patients with follow-up exceeding 1 year. The log transformation of the number of allergies for lumbar patients predicted a significantly increased cost of admission (β=$3,597, p<.01) and trended toward significance among cervical patients (β=$1,842, p=.10).Conclusions: Patient-reported allergies correlate with subjective improvement in pain and disability after spine surgery and may serve as a marker of postoperative outcomes. The relationship between allergies and PDQ improvement may be secondary to the short-term expectation-actuality discrepancy, as this relationship was not durable beyond 1 year. [ABSTRACT FROM AUTHOR]

Background Context: Relative value units (RVUs) are a compensation model based on the effort required to provide a procedure or service to a patient. Thus, procedures that are more complex and require greater technical skill and aftercare, such as multilevel spine surgery, should provide greater physician compensation. However, there are limited data comparing RVUs with operative time. Therefore, this study aims to compare mean (1) operative times; (2) RVUs; and (3) RVU/min between posterior segmental instrumentation of 3-6, 7-12, and ≥13 vertebral segments, and to perform annual cost difference analysis.Methods: A total of 437 patients who underwent instrumentation of 3-6 segments (Cohort 1, current procedural terminology [CPT] code: 22842), 67 patients who had instrumentation of 7-12 segments (Cohort 2, CPT code: 22843), and 16 patients who had instrumentation of ≥13 segments (Cohort 3, CPT code: 22844) were identified from the National Surgical Quality Improvement Program (NSQIP) database. Mean operative times, RVUs, and RVU/min, as well as an annualized cost difference analysis, were calculated and compared using Student t test. This study received no funding from any party or entity.Results: Cohort 1 had shorter mean operative times than Cohorts 2 and 3 (217 minutes vs. 325 minutes vs. 426 minutes, p<.05). Cohort 1 had a lower mean RVU than Cohorts 2 and 3 (12.6 vs. 13.4 vs. 16.4). Cohort 1 had a greater RVU/min than Cohorts 2 and 3 (0.08 vs. 0.05, p<.05; vs. 0.08 vs. 0.05, p>.05). A $112,432.12 annualized cost difference between Cohorts 1 and 2, a $176,744.76 difference between Cohorts 1 and 3, and a $64,312.55 difference between Cohorts 2 and 3 were calculated.Conclusion: The RVU/min takes into account not just the value provided but also the operative times required for highly complex cases. The RVU/min for fewer vertebral level instrumentation being greater (0.08 vs. 0.05), as well as the $177,000 annualized cost difference, indicates that compensation is not proportional to the added time, effort, and skill for more complex cases. [ABSTRACT FROM AUTHOR]

Background Context: Degenerative changes in the cervical spine occur in an age-dependent manner. As the US population continues to age, the incidence of age-dependent, multilevel, degenerative cervical pathologies is expected to increase. Similarly, the average age of patients with cervical spondylotic myelopathy (CSM) will likely trend upward. Posterior cervical fusion (PCF) is often the treatment modality of choice in the management of multilevel cervical spine disease. Although outcomes following anterior cervical fusion for degenerative disease have been studied among older patients (aged 80 years and older), it is unknown if these results extend to octogenarian patients undergoing PCF for the surgical management of CSM.Purpose: The present study aimed to quantify surgical outcomes following PCF for the treatment of CSM among the octogenarian patient population compared with patients younger than 80 years old.Study Design/setting: This was a retrospective study that used the National Surgical Quality Improvement Program (NSQIP).Patient Sample: The sample included patients aged 60-89 who had CSM and who underwent PCF from 2012 to 2014.Outcome Measures: The outcome measures were multimorbidity, prolonged length of stay (LOS), discharge disposition (to home or skilled nursing/rehabilitation facility), 30-day all-cause readmission, and 30-day reoperation.Methods: The NSQIP database was queried for patients with CSM (International Classification of Disease, Ninth Revision, Clinical Modification code 721.1) aged 60-89 who underwent PCF (Current Procedural Terminology code 22600) from 2012 to 2014. Cohorts were defined by age group (60-69, 70-79, 80-89). Data were collected on gender, race, elective or emergent status, inpatientor outpatient status, where patients were admitted from (home vs. skilled nursing facility), American Society of Anesthesiologists class, comorbidities, and single- or multilevel fusion. After controllingfor these variables, logistic regression analysis was used to compare outcome measures in the different age groups.Results: A total of 819 patients with CSM who underwent PCF (416 aged 60-69, 320 aged 70-79, and 83 aged 80-89) were identified from 2012 to 2014. Of the PCF procedures, 79.7% were multilevel. There were no significant differences in the odds of multimorbidity, prolonged LOS, readmission, or reoperation when comparing octogenarian patients with CSM with patients aged 60-69 or 70-79. Patients aged 60-69 and 70-79 were significantly more likely to be discharged to home than patients over 80 (odds ratio [OR] 4.3, 95% confidence interval [CI] 1.8-10.4, p<.0001, and OR 2.7, 95% CI 1.1-6.4, p=.0005, respectively).Conclusions: Compared with patients aged 60-69 and 70-79, octogenarian patients with CSM were significantly more likely to be discharged to a location other than home following PCF. After controlling for patient comorbidities and demographics, 80- to 89-year-old patients with CSM who underwent PCF did not differ in other outcomes when compared with the other age cohorts. These results can improve preoperative risk counseling and surgical decision-making. [ABSTRACT FROM AUTHOR]

Background Context: Postoperative urinary retention (POUR) is a very common postoperative complication of all surgeries (5%-70%) that may lead to complications such as urinary tract infection (UTI), bladder overdistension, autonomic dysregulation, and increased postoperative length of stay (LOS). Within the field of spine surgery, the reported incidence rate of POUR is highly variable (5.6%-38%). Lack of clear stratification of surgical level, spinal pathology, and inadequate sample size are major limitations of available studies concerning POUR following spine surgery, which may lead to inconsistency in the incidence of POUR and the ability to model its occurrence and consequences.Purpose: This study examines the incidence, predictive factors, and complications of POUR in patients undergoing elective posterior lumbar decompression with or without fusion for lumbar stenosis to eliminate bias from studying procedures done in different anatomical regions and with different approaches. Additionally, this study intends to identify the consequences of POUR.Study Design and Setting: A retrospective consecutive cohort analysis was performed to examine patients undergoing posterior lumbar decompression who did and did not develop POUR.Patient Sample: All patients undergoing posterior lumbar decompression with or without fusion for lumbar stenosis with claudication from January 2014 through December 2015 at our institution were evaluated. Patients under the age of 18 and patients with spinal malignancies or infections were excluded.Outcome Measures: Physiological measures included identification of POUR by evidence of reinsertion of a Foley catheter, use of straight catheterization postoperatively, or by a clear medical diagnosis with pharmacologic treatment. Other physiological measures included identification of development of UTI, sepsis, acute kidney injury (AKI), surgical site infection (SSI), or readmission within 90 days after surgery, as well as LOS and discharge disposition.Methods: The electronic medical record was searched for all patients meeting inclusion and exclusion criteria. Postoperative urinary retention was defined as reinsertion of a Foley catheter, use of straight catheterization postoperatively, or a clear medical diagnosis with pharmacologic treatment. Statistical analysis was performed in R statistical software package version 3.3.2. Multiple variable selection techniques were used to determine appropriate variables for regression models, and logistic models were fit to the development of POUR and postoperative complications, whereas a linear regression model was used for LOS.Results: Data were collected on 1,592 consecutive patients. Among the sample population, the mean age at surgery was 67 (standard deviation 10.1) and 45% of patients were women. The incidence rate of POUR was 17.1% (273/1592). Increased age (odds ratio [OR]=1.04; 95% confidence interval [CI], 1.02-1.06; p<.001), benign prostatic hyperplasia (BPH) (OR=1.92; 95% CI, 1.32-2.78); p<.001), previous AKI (OR=3.29; 95% CI, 1.11-9.29; p=.025), and previous UTI (OR=1.69; 95% CI, 1.24-2.24; p<.001) significantly increased the probability of developing POUR. Factors including increased body mass index, coronary artery disease, congestive heart failure, diabetes mellitus, chronic obstructive pulmonary disease, tobacco use, and fusion were found to be non-significant and were excluded from the model. With respect to complications, POUR was found to be associated with development of UTI (OR=4.50; 95% CI, 3.14-6.45; p<.001), sepsis (OR=4.05; 95% CI, 1.16-13.55; p=.022), increased LOS (p<.001), increased likelihood to be discharged to a skilled nursing facility (SNF) (OR of discharge to home=0.44; 95% CI, 0.32-0.62; p<.001), and increased risk of readmission within 90 days of the index surgery (OR=1.60; 95% CI, 1.11-2.26; p=.009). Development of POUR did not increase the risk of developing AKI (OR=2.45; 95% CI, 0.93-6.30; p=.063) or a SSI (OR=1.09; 95% CI, 0.56-2.02; p=.79).Conclusions: Overall, POUR was a significant risk factor for the development of UTI, sepsis, increased LOS, discharge to a SNF, and readmission within 90 days. Surgeons and anesthesiologists should take preventative measures against POUR in individuals with increased age, BPH, AKI, and UTI within 90 days before surgery, as these factors were found to significantly increase the risk of POUR. [ABSTRACT FROM AUTHOR]

Background Context: There is significant variability in the materials commonly used for interbody cages in spine surgery. It is theorized that three-dimensional (3D)-printed interbody cages using porous titanium material can provide more consistent bone ingrowth and biological fixation.Purpose: The purpose of this study was to provide an evidence-based approach to decision-making regarding interbody materials for spinal fusion.Study Design: A comparative animal study was performed.Methods: A skeletally mature ovine lumbar fusion model was used for this study. Interbody fusions were performed at L2-L3 and L4-L5 in 27 mature sheep using three different interbody cages (ie, polyetheretherketone [PEEK], plasma sprayed porous titanium-coated PEEK [PSP], and 3D-printed porous titanium alloy cage [PTA]). Non-destructive kinematic testing was performed in the three primary directions of motion. The specimens were then analyzed using micro-computed tomography (µ-CT); quantitative measures of the bony fusion were performed. Histomorphometric analyses were also performed in the sagittal plane through the interbody device. Outcome parameters were compared between cage designs and time points.Results: Flexion-extension range of motion (ROM) was statistically reduced for the PTA group compared with the PEEK cages at 16 weeks (p-value=.02). Only the PTA cages demonstrated a statistically significant decrease in ROM and increase in stiffness across all three loading directions between the 8-week and 16-week sacrifice time points (p-value≤.01). Micro-CT data demonstrated significantly greater total bone volume within the graft window for the PTA cages at both 8 weeks and 16 weeks compared with the PEEK cages (p-value<.01).Conclusions: A direct comparison of interbody implants demonstrates significant and measurable differences in biomechanical, µ-CT, and histologic performance in an ovine model. The 3D-printed porous titanium interbody cage resulted in statistically significant reductions in ROM, increases in the bone ingrowth profile, as well as average construct stiffness compared with PEEK and PSP. [ABSTRACT FROM AUTHOR]

Background Context: The United States Centers for Disease Control and Prevention estimates the prevalence of inflammatory bowel disease (IBD) at more than 3.1 million people. As diagnostic techniques and treatment options for IBD improve, the prevalence of IBD is expected to increase. For spine surgeons, patients with IBD have a unique complication profile because patients with IBD may present with poor nutritional status and because the medications used to manage IBD have been associated with poor vertebral bone mineralization and immunosuppression. Presently, there are very limited data regarding perioperative outcomes among patients with IBD who undergo spinal surgery. The present study begins to address this knowledge gap by describing trends in patients with IBD undergoing lumbar fusion and by quantifying the association between IBD and immediate postoperative outcomes using a large, national database.Purpose: To advance our understanding of the potential pitfalls and risks associated with lumbar fusion surgery in patients with IBD.Design/setting: Retrospective cross-sectional analysis.Patient Sample: The Nationwide Inpatient Sample (NIS) database was queried from 1998 to 2011 to identify adult patients (18+) who underwent primary lumbar fusion operations using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding.Outcome Measures: Incidence of lumbar fusion procedures, prevalence of IBD, complication rates, length of stay, and total hospital charges.Methods: The annual number of primary lumbar fusion operations performed between 1998 and 2011 was obtained from the NIS database. Patients younger than 18 years of age were excluded. The prevalence of IBD in this population (both Crohn disease and ulcerative colitis) was determined using ICD-9-CM codes. Logistic regression models were estimated to determine the association between IBD and the odds of postoperative medical and surgical complications, while controlling for patient demographics, comorbidity burden, and hospital characteristics. The complex survey design of the NIS was taken into account by clustering on hospitals and assuming an exchangeable working correlation using the discharge weights supplied by the NIS. We accounted for multiple comparisons using the Bonferroni correction and an alpha level for statistical significance of . 0028.Results: The prevalence of IBD is increasing among patients undergoing lumbar fusion, from 0.21% of all patients undergoing lumbar fusion in 1998 to 0.48% of all patients undergoing lumbar fusion in 2011 (p<.001). The odds of experiencing a postoperative medical or surgical complication were not significantly different when comparing patients with IBD with control patients without IBD after controlling for patient demographics, comorbidity burden, and hospital characteristics (adjusted odds ratio=1.1, 95% confidence interval [CI] 0.99-1.3, p=.08). On multivariable analysis, the presence of IBD in patients undergoing lumbar fusion surgery was associated with longer length of stay and greater hospitalization charges.Conclusions: Among patients who underwent lumbar fusion, IBD is a rare comorbidity that is becoming increasingly more common. Importantly, patients with IBD were not at increased risk of postoperative complications. Spine surgeons should be prepared to treat more patients with IBD and should incorporate the present findings into preoperative risk counseling and patient selection. [ABSTRACT FROM AUTHOR]

Background Context: Lumbar fusion is an effective and durable treatment for symptomatic lumbar spondylolisthesis; however, the current literature provides insufficient evidence to recommend an optimal surgical fusion strategy.Purpose: The present study aims to compare the clinical outcomes, fusion rates, blood loss, and operative times between open posterolateral lumbar fusion (PLF) alone and open transforaminal lumbar interbody fusion (TLIF) + posterolateral fusion for spondylolisthesis.Study Design: This is a systematic literature review and meta-analysis of English language studies for the treatment of spondylolisthesis with PLF versus PLF + TLIF.Patient Sample: Data were obtained from published randomized controlled trials (RCTs) and retrospective cohort studies.Outcome Measures: Clinical outcomes included Oswestry Disability Index (ODI), back pain, leg pain, and health-related quality of life (HRQOL) scores. Fusion rate, operative time, blood loss, and infection rate were also assessed.Methods: A literature search of three electronic databases was performed to identify investigations performed comparing PLF alone with PLF + TLIF for treatment of low-grade lumbar spondylolisthesis. The summary effect size was assessed from pooling observational studies for each of the outcome variables, with odds ratios (ORs) used for fusion and infection rate, mean difference used for improvement in ODI and leg pain as well as operative time and blood loss, and standardized mean difference used for improvement in back pain and HRQOL outcomes. Studies were weighed based on the inverse of the variance and heterogeneity. Heterogeneity was assessed using the I2-an estimate of the error caused by between-study variation. Effect sizes from the meta-analysis were then compared with data from the RCTs to assess congruence in outcomes.Results: The initial literature search yielded 282 unique, English language studies. Seven were determined to meet our inclusion criteria and were included in our qualitative analysis. Five observational studies were included in our quantitative meta-analysis. The pooled fusion success rates were 84.7% (100/118) in the PLF group and 94.3% (116/123) in the TLIF group. Compared with TLIF patients, PLF patients had significantly lower odds of achieving solid arthrodesis (OR 0.33, 95% confidence interval [CI] 0.13-0.82, p=.02; I2=0%). With regard to improvement in back pain, the point estimate for the effect size was -0.27 (95% CI -0.43 to -0.10, p=.002; I2=0%), in favor of the TLIF group. For ODI, the pooled estimate for the effect size was -3.73 (95% CI -7.09 to -0.38, p=.03; I2=35%), significantly in favor of the TLIF group. Operative times were significantly shorter in the PLF group, with a summary effect size of -25.55 (95% CI -43.64 to -7.45, p<.01; I2=54%). No significant difference was observed in leg pain, HRQOL improvement, blood loss, or infection rate. Our meta-analysis results were consistent with RCTs, in favor of TLIF for achieving radiographic fusion and greater improvement in ODI and back pain.Conclusions: Our results demonstrate that for patients undergoing fusion for spondylolisthesis, TLIF is superior to PLF with regard to achieving radiographic fusion. However, current data only provide weak support, if any, favoring TLIF over PLF for clinical improvement in disability and back pain. [ABSTRACT FROM AUTHOR]

Background Context: Transforaminal lumbar interbody fusion (TLIF) or anterior lumbar interbody fusion with percutaneous pedicle screws (ALIFPS) offer significantly higher radiographic fusion rates than other fusion techniques for L5-S1 isthmic spondylolisthesis (IS). As it stands, there is a relative paucity of comparative data of the two techniques.Purpose: To define the clinical, radiographic, and financial differences between TLIF and ALIFPS for L5-S1 IS.Design/setting: A retrospective cohort study conducted at a single tertiary care center.Patient Sample: Sixty-six patients who underwent either TLIF or ALIPFS for L5-S1 IS at a single tertiary care center between 2009 and 2014.Outcome Measures: Quality of life outcome scores including the EuroQol-5 Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and Patient Health Questionnaire-9 (PHQ-9). Sagittal balance parameters including: pelvic incidence, pelvic tilt, sacral slope, segmental lordosis, total lordosis, degree of slip, disc height, and L1-axis S1 distance (LASD). Cost measures included in-hospital charges, hospital length of stay (LOS), and post-admission costs accrued over 1 year.Methods: Quality of life (QoL) outcome scores, radiographic data, and financial data were collected with a minimum of 1-year follow-up. Clinical results were investigated using the PDQ, PHQ-9, and EQ-5D. Radiographic measurements included lumbar lordosis, segmental lordosis, pelvic tilt, pelvic incidence, height of disc, L-1 axis S-1 distance, and the degree of slip. Cost data were generated based on patient-level resource utilization. Comparative data were presented as median with interquartile range (IQR). Continuous variables were compared using either independent Student t tests assuming unequal variance or Mann-Whitney U tests for parametric and nonparametric variables, respectively. The minimally clinical important difference (MCID) used for each questionnaire was as follows: PDQ (26), PHQ-9 (5), and EQ-5D (0.4).Results: A total of 66 patients met inclusion criteria. In the ALIFPS cohort, PDQ scores improved from 69 [47, 82] to 26 [18.2, 79.7], p=.02. In the TLIF cohort, PDQ scores improved from 73 [46, 85] to 48.5 [23, 67.5], p=.01. Both groups also showed a significant improvement in EQ-5D scores at 1 year, but the ALIFPS group showed a significantly greater improvement in EQ-5D scores at 1 year (0.1 [0,0.2] vs. 0.2 [0.1, 0.4], p=.02). Furthermore, only the ALIFPS cohort showed a significant improvement in segmental lordosis. The ALIFPS cohort showed a significantly greater improvement in disc height than did TLIF (3.5 [2, 5.5] vs. 6.7 [4.1, 10], p=.01). No significant differences were found in the direct costs of both procedures.Conclusions: Our findings suggest that anterior lumbar interbody fusion with percutaneous pedicle screws can achieve better clinical outcomes compared with TLIF for the treatment of IS. We believe the superior radiographic outcomes achieved through ALIFPS, namely a greater restoration of segmental lordosis and disc height, may have contributed to the improved clinical outcomes presented in the current study. [ABSTRACT FROM AUTHOR]

Background: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys are used to assess the quality of the patient experience following an inpatient stay. Hospital Consumer Assessment of Healthcare Providers and Systems scores are used to determine reimbursement for hospital systems and incentivize spine surgeons nationwide. There are conflicting data detailing whether early readmission or other postdischarge complications are associated with patient responses on the HCAHPS survey. Currently, the association between postdischarge emergency department (ED) visits and HCAHPS scores following lumbar spine surgery is unknown.Purpose: To determine whether ED visits within 30 days of discharge are associated with HCAHPS scores for patients who underwent lumbar spine surgery.Study Design: Retrospective cohort study.Patient Sample: A total of 453 patients who underwent lumbar spine surgery who completed the HCAHPS survey between 2013 and 2015 at a single tertiary care center.Outcome Measures: The HCAHPS survey-the Centers for Medicare and Medicaid Services' official measure of patient experience-results for each patient were analyzed as the primary outcome of this study.Methods: All patients undergoing lumbar spine surgery between 2013 and 2015 who completed an HCAHPS survey were studied. Patients were excluded from the study if they had been diagnosed with spinal malignancy or scoliosis. Patients who had an ED visit at our institution within 30 days of discharge were included in the ED visit cohort. The primary outcomes of this study include 21 measures of patient experience on the HCAHPS survey. Statistical analysis included Pearson chi-square for categorical variables, Student t test for normally distributed continuous variables, and Mann-Whitney U test for nonparametric variables. Additionally, log-binomial regression models were used to analyze the association between ED visits within 30 days after discharge and odds of top-box HCAHPS scores. No funds were received in support of this study, and the authors report no conflict of interest-associated biases.Results: After adjusting for patient-level covariates using log-binomial regression models, we found postdischarge ED visits were independently associated with lower likelihood of top-box score for several individual questions on HCAHPS. Emergency department visits within 30 days of discharge were negatively associated with perceiving your doctor as "always" treating you with courtesy and respect (risk ratio [RR] 0.26, p<.001), as well as perceiving your doctor as "always" listeningcarefully to you (RR 0.40, p=.003). Also, patients with an ED visit were less likely to feel as if their preferences were taken into account when leaving the hospital (RR 0.61, p=.008), less likely to recommend the hospital to family or friends (RR 0.46, p=.020), and less likely to rate the hospital as a 9 or a 10 out of 10, the top-box score (RR 0.43, p=.005).Conclusions: Our results demonstrate a strong association between postdischarge ED visits and low HCAHPS scores for doctor communication, discharge information, and global measures of hospital satisfaction in a lumbar spine surgery population. [ABSTRACT FROM AUTHOR]

Background Context: The patient experience of care as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is currently used to determine hospital reimbursement. The current literature inconsistently demonstrates an association between patient satisfaction and surgical outcomes.Purpose: To determine whether patient satisfaction with hospital experience is associated with better clinical outcomes in lumbar spine surgery.Study Design: A retrospective cohort study conducted at a single institution.Patient Sample: A total of 249 patients who underwent lumbar spine surgery between 2013 and 2015 and completed the HCAHPS survey.Outcome Measures: Self-reported health status measures, including the EuroQol 5 Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and visual analog score for back pain (VAS-BP).Methods: All patients undergoing lumbar spine surgery between 2013 and 2015 who completed an HCAHPS survey were studied. Patients were excluded from the study if they had been diagnosed with spinal malignancy, scoliosis, or had less than 1 year of follow-up. Patients who selected a 9 or 10 overall hospital rating (OHR) on HCAHPS were placed in the satisfied group, and the remaining patients comprised the unsatisfied group. The primary outcomes of this study include patient-reported health status measures such as EQ-5D, PDQ, and VAS-BP. No funds were received in support of this study, and the authors report no conflict of interest-associated biases.Results: Our study population consisted of 249 patients undergoing lumbar spine surgery. Of these, 197 (79%) patients selected an OHR of 9 or 10 on the HCAHPS survey and were included in the satisfied group. The only preoperative characteristics that differed significantly between the twogroups were gender, a diagnosis of degenerative disc disease (DDD), heavy preoperative narcotic use, and a diagnosis of chronic renal failure. At 1 year follow-up, no statistically significant differences in EQ-5D, PDQ, or VAS-BP were observed. After using multivariable linear regression models to assess the association between patient satisfaction and pre- to 1-year postoperative changes in health status measures, selecting a top-box OHR was not found to be significantly associated with change in either EQ-5D (beta=0.055 [95% confidence interval {CI}: -0.035 to 0.145]), PDQ (beta=-9.013 [95% CI: -23.782 to 5.755]), or VAS-BP (beta=-0.849 [95% CI: -2.125 to 0.426]). These results suggest high satisfaction with the hospital experience may not necessarily correlate with favorable clinical outcomes.Conclusions: Top-box OHR was not associated with pre- to 1-year postoperative improvement in EQ-5D, PDQ, and VAS-BP. Although the associations between high satisfaction and improvement in health status did not reach statistical significance, the best estimates from our multivariable models reflect greater clinical improvement with top-box satisfaction. Future studies should seek to investigate whether HCAHPS are a reliable indicator of quality care in lumbar spine surgery. [ABSTRACT FROM AUTHOR]

Background Context: Lumbar fusion is a common and costly procedure in the United States. Reimbursement for surgical procedures is increasingly tied to care quality and patient safety as part of value-based reimbursement programs. The incidence of adverse quality events among lumbar fusion patients is unknown using the definition of care quality (patient safety indicators [PSI]) used by the Centers for Medicare and Medicaid Services (CMS). The association between insurance status and the incidence of PSI is similarly unknown in lumbar fusion patients.Purpose: This study sought to determine the incidence of PSI in patients undergoing inpatient lumbar fusion and to quantify the association between primary payer status and PSI in this population.Study Design: A retrospective cohort study was carried out.Patient Sample: The sample comprised all adult patients aged 18 years and older who were included in the Nationwide Inpatient Sample (NIS) that underwent lumbar fusion from 1998 to 2011.Outcome Measure: The incidence of one or more PSI, a validated and widely used metric of inpatient health-care quality and patient safety, was the primary outcome variable.Methods: The NIS data were examined for all cases of inpatient lumbar fusion from 1998 to 2011. The incidence of adverse patient safety events (PSI) was determined using publicly available lists of the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Logistic regression models were used to determine the association between primary payer status (Medicaid and self-pay relative to private insurance) and the incidence of PSI.Results: A total of 539,172 adult lumbar fusion procedures were recorded in the NIS from 1998 to 2011. Patients were excluded from the secondary analysis if "other" or "missing" was listed for primary insurance status. The national incidence of PSI was calculated to be 2,445 per 100,000 patient years of observation, or approximately 2.5%. In a secondary analysis, after adjusting for patient demographics and hospital characteristics, Medicaid and self-pay patients had significantly greater odds of experiencing one or more PSI during the inpatient episode relative to privately insured patients (odds ratio 1.16, 95% confidence interval 1.07-1.27).Conclusions: Among patients undergoing inpatient lumbar fusion, insurance status is associated with the adverse health-care quality events used to determine hospital reimbursement by the CMS. The source of this disparity must be studied to improve the quality of care delivered to vulnerable patient populations. [ABSTRACT FROM AUTHOR]

Background Context: The Centers for Medicare and Medicaid Services (CMS) defines "adverse quality events" as the incidence of certain complications such as postsurgical hematoma or iatrogenic pneumothorax during an inpatient stay. Patient safety indicators (PSI) are a means to measure the incidence of these adverse events. When adverse events occur, reimbursement to the hospital decreases. The incidence of adverse quality events among patients hospitalized for primary spinal neoplasms is unknown. Similarly, it is unclear what the impact of insurance status is on adverse care quality among this patient population.Purpose: We aimed to determine the incidence of PSI among patients admitted with primary spinal neoplasms, and to determine the association between insurance status and the incidence of PSI in this population.Study Design: This is a retrospective cohort study.Patient Sample: We included all patients, 18 years and older, in the Nationwide Inpatient Sample (NIS) who were hospitalized for primary spine neoplasms from 1998 to 2011.Outcome Measures: Incidence of PSI from 1998 to 2011 served as outcome variable.Methods: The NIS was queried for all hospitalizations with a diagnosis of primary spinal neoplasm during the inpatient episode from 1998 to 2011. Incidence of PSI was determined using publicly available lists of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. Logistic regression models were used to determine the effect of primary payer status on PSI incidence. All comparisons were made between privately insured patients and Medicaid or self-pay patients.Results: We identified 6,095 hospitalizations in which a primary spinal neoplasm was recorded during the inpatient episode. We excluded patients younger than 18 years and those with "other" or "missing" primary insurance status, leaving 5,880 patients for analysis. After adjusting for patient demographics and hospital characteristics, Medicaid or self-pay patients had significantly greater odds of experiencing one or more PSI (odds ratio [OR] 1.81 95% confidence interval [CI] 1.11-2.95) relative to privately insured patients.Conclusions: Among patients hospitalized for primary spinal neoplasms, primary payer status predicts the incidence of PSI, an indicator of adverse health-care quality used to determine hospital reimbursement by the CMS. As reimbursement continues to be intertwined with reportable quality metrics, identifying vulnerable populations is critical to improving patient care. [ABSTRACT FROM AUTHOR]

Background Context: Multiple studies have determined minimum clinically important difference (MCID) thresholds for EuroQOL-5 Dimensions (EQ-5D) scores in lumbar fusion patients. However, a comprehensive understanding of predictors for a clinically significant improvement (CSI) postoperatively does not exist.Purpose: To determine medical, radiographic, and surgical predictors for obtaining a CSI following lumbar fusion surgery.Study Design: This is a retrospective review of patients who underwent instrumented lumbar fusion.Patient Sample: We included patients who underwent lumbar fusion for any indication between 2008 and 2013.Outcome Measures: Outcome measures included preoperative and postoperative EQ-5D Index scores.Materials and Methods: The medical records of patients who received a lumbar fusion for any indication were retrospectively reviewed to identify patient medical and surgical characteristics. A blinded reviewer assessed radiographs for each patient to examine sagittal alignment following fusion. Multivariable logistic regression was used to model the achievement of a CSI based on two commonly cited MCID values.Results: A total of 231 patients fit the inclusion criteria; 58% exceeded an MCID value for an EQ-5D score of 0.100, and 16% exceeded an MCID value of 0.390. Statistically significant independent predictors of not obtaining a CSI for an MCID threshold of 0.100 included a higher preoperative EQ-5D score (odds ratio [OR]=44.8) and L5-S1 fusion (OR=3.3). For an MCID value of 0.390, a higher preoperative EQ-5D score (OR=2,080.8) and a diagnosis of depression (OR=7.1) were predictive of not achieving a CSI, whereas spondylolisthesis (OR=4.1) was predictive of obtaining a CSI postoperatively. For both MCID values, patients who achieved a CSI had better postoperative quality of life (QOL) scores for all metrics measured, despite worse QOL scores preoperatively.Conclusions: This study is the first to use a combination of medical, surgical, and postoperative sagittal balance variables as determinants for the achievement of a CSI after lumbar fusion. The awareness of these predictors may allow for better patient selection and surgical approach to decrease the probability of acquiring a poor outcome postoperatively. [ABSTRACT FROM AUTHOR]

Background Context: The incidence of adverse care quality events among patients undergoing cervical fusion surgery is unknown using the definition of care quality employed by the Centers for Medicare and Medicaid Services (CMS). The effect of insurance status on the incidence of these adverse quality events is also unknown.Purpose: This study determined the incidence of hospital-acquired conditions (HAC) and patient safety indicators (PSI) in patients with cervical spine fusion and analyzed the association between primary payer status and these adverse events.Study Design: This is a retrospective cohort design.Patient Sample: All patients in the Nationwide Inpatient Sample (NIS) aged 18 and older who underwent cervical spine fusion from 1998 to 2011 were included.Outcome Measures: Incidence of HAC and PSI from 1998 to 2011 served as outcome variables.Methods: We queried the NIS for all hospitalizations that included a cervical fusion during the inpatient episode from 1998 to 2011. All comparisons were made between privately insured patients and Medicaid or self-pay patients because Medicare enrollment is confounded with age. Incidence of nontraumatic HAC and PSI was determined using publicly available lists of International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. We built logistic regression models to determine the effect of primary payer status on PSI and nontraumatic HAC.Results: We identified 419,424 hospitalizations with cervical fusion performed during an inpatient episode. The estimated national incidences of nontraumatic HAC and PSI were 0.35% and 1.6%, respectively. After adjusting for patient demographics and hospital characteristics, Medicaid or self-pay patients had significantly greater odds of experiencing one or more HAC (odds ratio [OR] 1.51 95% conflict of interest [CI] 1.23-1.84) or PSI (OR 1.52 95% CI 1.37-1.70) than the privately insured cohort.Conclusions: Among patients undergoing inpatient cervical fusion, primary payer status predicts PSI and HAC (both indicators of adverse health-care quality used to determine hospital reimbursement by CMS). As the US health-care system transitions to a value-based payment model, the cause of these disparities must be studied to improve the quality of care delivered to vulnerable patient populations. [ABSTRACT FROM AUTHOR]

Background Context: Coexisting Parkinson's disease (PD) and cervical spondylotic myelopathy (CSM) presents a diagnostic and therapeutic challenge due to symptomatic similarities between the diseases. Whereas CSM patients are routinely treated with surgery, PD patients face poorer outcomes following spine surgery. No studies have investigated the quality of life (QOL) outcomes following decompression in coexisting PD and CSM.Purpose: The purpose of the present study was to characterize QOL outcomes for patients with coexisting PD and CSM following cervical decompression.Study Design/setting: This is a matched cohort study at a single tertiary-care center.Patient Sample: Patients with coexisting PD and CSM undergoing cervical decompression between June 2009 and December 2014 were included. These patients were matched to controls with CSM alone by age, gender, American Society of Anesthesiologists classification, Modified Japanese Orthopaedic Association scores, and operative parameters.Outcome Measures: The primary outcome measure was QOL outcomes assessed by change in the EuroQol 5-Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and Patient Health Questionnaire-9 (PHQ-9) at last follow-up (LFU). Change in QOL exceeding the minimal clinically important difference (MCID) was secondary.Methods: QOL data were collected using the institutional prospectively collected database of patient-reported health status measures. Simple and multivariable regressions were used to assess the impact of PD upon change in QOL.Results: Eleven PD patients were matched to 44 controls. Control patients experienced QOL improvement across all three measures, whereas PD patients only improved with respect to PDQ(89.9-80.7, p=.03). Despite no significant differences in preoperative QOL, PD patients experienced poorer QOL at LFU in EQ-5D (0.526 vs. 0.707, p=.01) and PDQ (80.7 vs. 51.4, p=.03), and less frequently achieved an EQ-5D MCID (18% vs. 57%, p=.04). However, no differences in the achievement of an MCID in PDQ or PHQ-9 were observed between cohorts. Multivariable regression identified PD as a significant independent predictor of poorer improvement in EQ-5D (β=-0.09, p<.01) and failure to achieve an EQ-5D MCID (odds ratio: 0.08, p<.01).Conclusions: This is the first study to characterize QOL outcomes following cervical decompression for patients with coexisting PD and CSM. Although myelopathy may have been less severe among PD patients, a significant reduction in pain-related disability was observed following decompression. However, PD predicted diminished improvement in overall QOL measured by the EQ-5D. [ABSTRACT FROM AUTHOR]

Background Context: Nearly 70% of patients with multiple myeloma (MM) experience vertebral fracture. As a consequence, these patients suffer significantly poorer quality of life. However, no studies have characterized the natural progression of these fractures.Purpose: The purpose of this study was to characterize the progression of MM-associated vertebral fractures.Study Design/setting: A consecutive retrospective chart review at a single tertiary-care center was carried out.Patient Sample: Patients with MM and pathologic vertebral fracture with at least one follow-up between January 2007 and December 2013 were included. Radiographic measurements were recorded until last follow-up (LFU) or until surgical intervention or patient death. Patients with a history of vertebral fracture not associated with MM were excluded.Outcome Measures: The primary outcome measure was change in height of the fractured vertebrae. Fractures were characterized by Genant grade and morphology.Methods: At baseline and each follow-up, anterior, middle, and posterior vertebral body heights were measured from midline sagittal T1-weighted magnetic resonance imaging. Student t tests and Fisher exact tests were performed to identify variables associated with fracture progression.Results: Among 33 patients, 67 fractures were followed. Sixty-four percent of patients were female, with a mean age of 66. Baseline mean anterior, middle, and posterior vertebral body height losses were 30%, 36%, and 15%, respectively. Forty-three percent of fractures were Genant grade 3, and 57% were biconcave. Mean time to LFU was 40 months. At LFU, mean anterior, middle, and posterior vertebral body height losses increased to 47% (p<.01), 49% (p<.01), and 28% (p<.01), respectively. More fractures became Genant grade 3 (75%, p<.01) and wedge (54%, p=.03). On average, patients lost 0.83% in vertebral body height per month, with initial Genant grade 1 fractures progressing most rapidly (1.69%/month, p<.01). Patients treated with bisphosphonates suffered less additional height loss compared with untreated patients (14% vs. 24%, p=.07).Conclusions: We observed significant fracture progression despite high utilization of bisphosphonates. Patients lost nearly 1% of additional vertebral body height per month, with the least severe presenting fractures progressing most rapidly, highlighting the necessity for early referral to spine specialists and evidence-based guidelines for surveillance and treatment in the myeloma population. [ABSTRACT FROM AUTHOR]

Background Context: Patients with comorbid disease may experience suboptimal quality of life (QOL) improvement following decompression spinal surgery. Prior studies have suggested the deleterious effect of diabetes upon postoperative QOL; however, these studies have not used minimal clinically important differences (MCIDs) or multivariable statistical techniques.Purpose: The purpose of this study was to assess the effect of preoperative diabetes upon postoperative change in QOL.Study Design/setting: A retrospective cohort study at a single tertiary-care center was carried out.Patient Sample: Patients who underwent lumbar decompression between 2008 and 2014 were included in the study. Inclusion necessitated a minimum follow-up of 6 months.Outcomes Measures: Postoperative changes in the EuroQol 5-Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and Patient Health Questionnaire 9 (PHQ-9) at last follow-up were the primary outcome measures. The secondary outcome variable was postoperative change in QOL measures exceeding the MCID.Methods: Quality of life data were collected using the institutional prospectively collected database of patient-reported health status measures. Simple and multivariable logistic regressions were used to assess the impact of diabetes upon normalized change in QOL and improvement exceeding the MCID.Results: There were 212 patients who met inclusion criteria. Whereas non-diabetics experienced significant improvements in EQ-5D, PDQ, and PHQ-9 (p<.01), diabetics experienced no significant changes in any measures. More non-diabetics achieved the EQ-5D MCID compared with diabetics (55% vs. 23%, p<.01). Following multivariable regression, chronic kidney disease (CKD, β=-0.15, p=.04) and diabetes (β=-0.05, p=.04) were identified as significant independent predictors of diminished improvement in EQ-5D postoperatively. Furthermore, diabetes was also identified as a significant independent predictor of failure to achieve an EQ-5D MCID (OR 0.20, p<.01), whereas CKD trended toward predicting diminished improvement (OR<0.01, p=.09).Conclusion: The burden of comorbidities may impact the QOL benefit of decompression spine surgery. In the present study, diabetes was found to independently predict diminished improvement in QOL after lumbar decompression. [ABSTRACT FROM AUTHOR]

Background Context: Atlantoaxial fusion is used to correct atlantoaxial instability that is often secondary to traumatic fractures, Down syndrome, or rheumatoid arthritis. The effect of age and comorbidities on outcomes following atlantoaxial fusion is unknown.Purpose: This study aimed to better understand trends and predictors of outcomes and charges following atlantoaxial fusion and to identify confounding variables that should be included in future prospective studies.Study Design: A retrospective analysis of data from the Nationwide Inpatient Sample (NIS), a nationally representative, all-payer database of inpatient diagnoses and procedures in the United States.Patient Sample: We included all patients who underwent atlantoaxial fusion (International Classification of Disease, Ninth Revision, Clinical Modification code 81.01) between 1998 and 2011 who were 18 years or older at the time of admission.Outcome Measures: Outcome measures included in-hospital charges, hospital length of stay (LOS), in-hospital mortality, and discharge disposition.Methods: Predictors of outcome following atlantoaxial fusion were assessed using a series of univariable analyses. Those predictors with a p-value of less than .2 were included in the final multivariable models. Independent predictors of outcome were those that were significant at an alpha level of 0.05 following inclusion in the final multivariable models. Logistic regression was used to determine predictors of in-hospital mortality and discharge disposition whereas linear regression was used to determine predictors of hospital charges and LOS. Discharge weights were used to produce generalizable results.Results: From 1998 to 2011, there were 8,914 hospitalizations recorded wherein atlantoaxial fusion was performed during the inpatient hospital stay. Of these hospitalizations, 8,189 (91.9%) met inclusion criteria. Of the study sample, 62% was white, and the majority of patients were either insured by Medicare (47.2%) or had private health insurance (35.6%). The most common comorbidity as defined by the NIS and the Elixhauser comorbidity index was hypertension (43.2%). The in-hospital mortality rate for the study population was 2.7%, and the median LOS was 6.0 days. The median total charge (inflation adjusted) per hospitalization was $73,561. Of the patients, 48.9% were discharged to home. Significant predictors of in-hospital mortality included increased age, emergent or urgent admissions, weekend admissions, congestive heart failure, coagulopathy, depression, electrolyte disorder, metastatic cancer, neurologic disorder, paralysis, and non-bleeding peptic ulcer. Many of these variables were also found to be predictors of LOS, hospital charges, and discharge disposition.Conclusion: This study found that older patients and those with greater comorbidity burden had greater odds of postoperative mortality and were being discharged to another care facility, had longer hospital LOS, and incurred greater hospital charges following atlantoaxial fusion. [ABSTRACT FROM AUTHOR]

Background Context: Patients with multiple myeloma (MM) incur significant degradation in quality of life because of progressive osteolytic vertebral fractures. No studies have investigated predictors of fracture progression, and limited data are available for predicting the development of future fractures.Purpose: The purpose of this study was to identify independent predictors of vertebral fracture progression and the development of future vertebral fracture.Study Design/setting: This is a consecutive retrospective chart review at a single tertiary-care center.Patient Sample: Patients with MM and pathologic vertebral fracture with radiographic follow-up between January 2007 and December 2013 were included. Radiographic measurements were recorded at presentation with fracture and first follow-up (FFU) after at least three months. Patients with a history of vertebral fracture not associated with MM were excluded.Outcome Measures: The primary outcome measure was the rate of vertebral body height loss. The development of future vertebral fracture was secondary.Methods: Anterior, middle, and posterior vertebral body heights were measured from midline sagittal T1-weighted magnetic resonance imaging (MRI). Future fracture-free survival was calculated using Kaplan-Meier analysis. Multivariable regression was used to identify independent predictors of the rate of vertebral height loss. Multivariable Cox proportional hazards modeling was used to identify predictors of developing future vertebral fracture.Results: Thirty-three patients with 67 fractures were followed for a median of 10.8 months to FFU. Sixty-four percent of the patients were female and the median age was 66. The median additional vertebral height loss between presentation and FFU was 15%, whereas the median rate of vertebral height loss was 1.01%/month. More rapid vertebral height loss was predicted by dyslipidemia (β=0.36, p=.05), previous non-vertebral pathologic fracture related to MM (β=0.51, p=.01), and Durie-Salmon Stage III (β=0.66, p=.06). The median time to future fracture was 25.1 months; the 5-year future fracture-free survival rate was 34%. Osteopenia/osteoporosis (hazard ratio [HR]: 9.28, p<.01), serum light chains (HR: 1.37, p=.06), and serum calcium (HR: 1.62, p=.05) predicted the development of future vertebral fracture.Conclusions: We observed significant fracture progression over a short follow-up period. Several comorbidities and laboratory measures predicted more rapid vertebral height loss and the development of future fracture. Identifying risk factors for increased fracture burden may allow spine specialists to pursue earlier and appropriate intervention to optimize function and minimize morbidity. [ABSTRACT FROM AUTHOR]

Background Context: Cervical arthroplasty is an increasingly popular alternative for the treatment of cervical radiculopathy and myelopathy. This technique preserves motion at the index and adjacent disc levels, avoiding the restraints of fusion and potentially minimizing adjacent segment pathology onset during the postoperative period.Purpose: This study aimed to identify all prospective studies reporting adjacent segment pathology rates for cervical arthroplasty.Study Design/setting: Systematic review and meta-analysis were carried out.Patient Sample: Studies reporting adjacent segment degeneration (ASDegeneration) and adjacent segment disease (ASDisease) rates in patients who underwent cervical arthroplasty comprised the patient sample.Outcome Measures: Outcomes of interest included reported ASDegeneration and ASDisease events after cervical arthroplasty.Methods: We conducted a MEDLINE, SCOPUS, and Web of Science search for studies reporting ASDegeneration or ASDisease following cervical arthroplasty. A meta-analysis was performed to calculate effect summary values, 95% confidence intervals (CIs), Q values, and I(2) values. Forest plots were constructed for each analysis group.Results: Of the 1,891 retrieved articles, 32 met inclusion criteria. The patient incidence of ASDegeneration and ASDisease was 8.3% (95% CI 3.8%-12.7%) and 0.9% (95% CI 0.1%-1.7%), respectively. The rate of ASDegeneration and ASDisease at individual levels was 10.5% (95% CI 6.1%-14.9%) and 0.2% (95% CI -0.1% to 0.5%), respectively. Studies following patients for 12-24 months reported a 5.1% (95% CI 2.1%-8.1%) incidence of ASDegeneration and 0.2% (95% CI 0.1%-0.2%) incidence of ASDisease. Conversely, studies following patients for greater than 24 months reported a 16.6% (5.8%-27.4%) incidence of ASDegeneration and 2.6% (95% CI 1.0%-4.2%) of ASDisease. This identified a statistically significant increase in ASDisease diagnosis with lengthier follow-up. Additionally, 1- and 2-level procedures resulted in a 7.4% (95% CI 3.3%-11.4%) and15.6% (95 CI-9.2% to 40.4%) incidence of ASDegeneration, respectively. Although there was an 8.2% increase in ASDegeneration following 2-level operations (relative to 1-level), it did not reach statistical significance. We were unable to analyze ASDisease incidence following 2-level arthroplasty (too few cases), but 1-level operations resulted in an ASDisease incidence of 0.8% (95% CI 0.1%-1.5%).Conclusions: This review represents a comprehensive estimation of the actual incidence of ASDegeneration and ASDisease across a heterogeneous group of surgeons, patients, and arthroplasty techniques. Our investigation should serve as a framework for individual surgeons to understand the impact of various cervical arthroplasty techniques, follow-up duration, and surgical levels on the incidence of ASDegeneration and ASDisease during the postoperative period. [ABSTRACT FROM AUTHOR]

Background Context: Nearly 80% of patients with newly diagnosed multiple myeloma (MM) have bony lesions on magnetic resonance imaging (MRI). These lesions may progress to debilitating vertebral fractures. No studies have quantitatively characterized these fractures or identified predictors of fracture burden and severity.Purpose: The purpose of this study was to characterize the clinical and radiologic features of these fractures and to identify independent predictors of fracture burden and severity.Study Design/setting: A consecutive retrospective chart review was conducted from January 2007 to December 2013 at a single tertiary-care institution.Patient Sample: Patients with diagnoses of both MM and vertebral fracture were included in this study. Those with a history of non-MM vertebral fracture were excluded.Outcome Measures: The primary outcome measure was height loss of the fractured vertebral body, whereas secondary outcome measures included number of fractures and morphology.Methods: Data were collected at fracture presentation. Radiologic data were obtained from T1-weighted MRI. Anterior, middle, and posterior vertebral body height losses were recorded, and a Genant grading was made. Multivariable Poisson and logistic regression were performed to identify predictors of fracture burden and severity.Results: Among 50 patients presenting with vertebral fracture, 124 fractures were observed. The majority (76%) of these patients did not have a previous MM diagnosis. The most common presenting symptom was back pain (84%), followed by neurologic (54%) and constitutional (50%) symptoms. The mean anterior, middle, and posterior height losses of the fractured vertebral body were 30%, 37%, and 16%, respectively. Twenty percent of fractures were Genant Grade 1 (mild), whereas 32% and 48% were grades 2 (moderate) and 3 (severe). Fifty-five percent of fractures were biconcave, whereas 32% and 13% were wedge and crush fractures. Lower body mass index and albumin and increased myeloma protein, light chains, and creatinine predicted an increased number of fractures at presentation. Increased β2-microglobulin and creatinine predicted more severe vertebral fractures.Conclusions: In the present study, 124 fractures were observed among 50 patients. These fractures were generally severe, biconcave, and in the thoracic spine. Laboratory signs of advanced MM predict greater fracture burden and severity. In the future, monitoring of these predictors may raise suspicion for an MM-associated vertebral fracture. [ABSTRACT FROM AUTHOR]

Background Context: Various posterolateral approaches exist to access ventral thoracic spinal canal pathologies. Selecting the optimal surgical approach requires sound understanding of the exposure and working angle afforded by each approach.Purpose: The purpose of this study was to quantify exposure of the ventral spinal canal with various posterolateral thoracic spinal approaches and to determine how regional anatomical differences affect measurements.Study Design: This is a quantitative anatomical cadaveric study.Methods: Four fresh cadaveric C7-L1 specimens were used with a saline infusion model to mimic in vivo thecal sac dimensions. Using stereotactic navigation, we measured exposure (expressed as percentage of total width) and maximum approach angle of the ventral spinal canal without thecal sac retraction after each surgical condition: laminectomy (L), 50% medial facetectomy (MF), transpedicular (TP), costotransversectomy (CTV), and lateral extracavitary (LE). The thoracic spine was divided into four regions (T1-T2, T3-T6, T7-T10, and T9-T12). A two-sided paired t test was used.Results: At T1-T2, visualized exposures were 25.8%, 31.5%, 42.3%, 45.1%, and 46.8%, respectively, after each surgical condition. Costotransversectomy and LE did not provide significant increase in exposure compared with the preceding condition. At T3-T6, exposures were 19.1%, 29.6%, 38.7%, 44.4%, and 44.5%, respectively. Only LE did not provide significant increase in exposure compared with the preceding condition. At T7-T10, visualized exposures were 17.9%, 30.6%, 39.9%, 44.9%, and 53.3%, respectively. All successive surgical conditions provided a significant increase in exposure. At T11-T12, visualized exposures were 14.2%, 25.8%, 43.1%, 47.7%, and 52.7%, respectively. Only LE did not provide a significant increase in exposure compared with the preceding condition. Each successive surgical condition provided a significantly increased lateral approach angle compared with the preceding condition, except LE at T1-T2. Maximum approach angle was more favorable at T1-T2 for L, MF, TP, and CTV compared with other thoracic regions.Conclusions: Medial facetectomy and TP approaches provide significantly increased exposure of the ventral spinal canal at all thoracic regions. Costotransversectomy provided significantly increased exposure compared with TP at T3-T12. Lateral extracavitary only provided significantly increased exposure compared with CTV at T7-T10. The results of this study can be used preoperatively to determine the optimal approach based on quantitative measurements and region-specific anatomical differences. [ABSTRACT FROM AUTHOR]

Background Context: Lumbar degenerative spondylolisthesis (LDS) is often diagnosed by conventional supine magnetic resonance imaging (MRI). Numerous studies have shown, however, that the degree of spondylolisthesis can be reduced or disappears when the patient is supine as compared with standing lateral and flexion-extension (SLFE) radiographs.Purpose: To compare the sensitivity of supine MRI with SLFE radiographs in patients with L4-L5 LDS.Study Design: A retrospective imaging study.Patient Sample: Included patients diagnosed with L4-L5 LDS with both SLFE films and supine MRI.Methods: Lumbar degenerative spondylolisthesis was defined radiographically as a slip greater than 4.5 mm. Mobile LDS was defined as a difference of greater than 3% in slip percentage between lateral radiographs and sagittal MRIs. Additional measurements included L4-L5 facet effusion diameter on axial MRIs. Measurements were performed by two independent examiners. The kappa coefficient was used to assess the interobserver agreement.Results: Of 103 patients assessed, 68% were women and the average age was 66 years. Lumbar degenerative spondylolisthesis was seen on 101 (98%) lateral films and 80 (78%) MRIs. Average slip was 10.0 mm for lateral standing radiographs and 6.6 mm on MRI (p<.0001). Fifty (48%) patients were identified with mobile LDS. The positive predictive value of facet joint effusion for mobile LDS increased from 52% for effusions greater than 1 mm to 100% for effusions greater than 3.5 mm.Conclusions: This study found that MRI had a sensitivity of 78% for detecting L4-L5 LDS compared with 98% for lateral standing films. We also identified facet effusion size as a marker to predict mobile LDS. These findings suggest that, particularly in the setting of facet effusions, the complete workup of patients in whom LDS is possible should include standing radiographs. [ABSTRACT FROM AUTHOR]

Background context Anterior cervical discectomy and fusion (ACDF) is a commonly performed procedure for patients presenting with cervical radiculopathy, myelopathy, or deformity. A systematic literature review and meta-analysis of pseudoarthrosis rates associated with ACDF with plate fixation have not been previously performed. Purpose The purpose of this study was to identify all prospective studies reporting pseudoarthrosis rates for ACDF with plate fixation. Study design/setting This study is based on a systematic review and meta-analysis. Patient sample Studies reporting pseudoarthrosis rates in patients who received one-, two-, or three-level ACDF surgeries were included. Outcome measures Outcomes of interest included reported pseudoarthrosis events after ACDF with plate fixation. Methods We conducted a MEDLINE, SCOPUS, Web of Science, and EMBASE search for studies reporting complications for ACDF with plate fixation. We recorded pseudoarthrosis events from all included studies. A meta-analysis was performed to calculate effect summary mean values, 95% confidence intervals (CIs), Q statistics, and I 2 values. Forest plots were constructed for each analysis group. Results Of the 7,130 retrieved articles, 17 met the inclusion criteria. The overall pseudoarthrosis rate was 2.6% (95% CI: 1.3–3.9). Use of autograft fusion (0.9%, 95% CI: –0.4 to 2.1) resulted in a reduced pseudoarthrosis rate compared with allograft fusion procedures (4.8%, 95% CI: 1.7–7.9). Studies were separated based on the length of follow-up: 12 to 24 and greater than 24 months. These groups reported rates of 3.1% (95% CI: 1.2–5.0) and 2.3% (95% CI: 0.1–4.4), respectively. Studies performing single-level ACDF yielded a rate of 3.7% (95% CI: 1.6–5.7). Additionally, there was a large difference in the rate of pseudoarthrosis in randomized controlled trials (4.8%, 95% CI: 2.6–7.0) versus prospective cohort studies (0.2%, 95% CI: –0.1 to 0.5), indicating that the extent of follow-up criteria affects the rate of pseudoarthrosis. Conclusions This review represents a comprehensive estimation of the actual incidence of pseudoarthrosis across a heterogeneous group of surgeons, patients, and ACDF techniques. The definition of pseudoarthrosis varied significantly within the literature. To ensure its diagnosis and prevent sequelae, standardized criteria need to be established. This investigation sets the framework for surgeons to understand the impact of surgical techniques on the rate of pseudoarthrosis. [ABSTRACT FROM AUTHOR]

Background Magnetic resonance imaging (MRI) is a vital tool for detection of soft tissue injury (STI) after cervical spine injury (CSI). However, high cost, prolonged imaging time, and limited use in hemodynamically unstable patients necessitates that the utility of MRI in all patients with CSI be scrutinized. Methods A retrospective review was performed of all patients treated for a CSI at a Level I trauma center between 2005 and 2010. Patient demographics, fracture characteristics, and associated STIs were collected. STIs were classified further into same level ligamentous injury, adjacent level ligamentous injury (ALLI), cord contusion, and traumatic herniated disc. ALLI was defined as anterior or posterior longitudinal ligament, ligamentum flavum, or supraspinous or interspinous ligamentous injury. Results MRI was performed in 240 of 787 patients. Evidence of STI was identified in 54.6%. ALLI was the most common STI (80 of 240 patients); these injuries were subdivided into above, below, or both above and below the concurrent fracture level. Patients with ALLI were significantly more likely to have injured C3 ( P < 0.01) and C5 ( P < 0.03) levels, association with widened disc space ( P = 0.03), and multiple CSIs ( P = 0.008). The whole ALLI was included in the fixation strategy in 100% of patients with ALLI only above the concurrent fracture level and 87% of patients with ALLI only below the concurrent fracture level. Conclusions MRI detected an associated STI in about 55% of patients who underwent imaging. Injuries involving multiple fractured cervical levels, fractures at C3 and C5, and widened disc space should raise the treating physician's level of suspicion for ALLI. Our data show that treatment directed by MRI findings in select cases has substantial value. [ABSTRACT FROM AUTHOR]