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Arthroplasty surgeons use a variety of patient-reported outcome measures (PROMs) to assess functional well-being, including the Knee Injury and Osteoarthritis Outcome Score (KOOS) Physical Function short form (KOOS-PS), Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Short Form 10a (PROMIS PF SF 10a), and PROMIS Global-10 Physical Health subscale. However, there is a paucity of literature assessing their concurrent validity and performance. Between June 2016 and December 2020, patient visits at an arthroplasty clinic for knee concerns were identified. Patients who completed KOOS-PS, PROMIS PF SF 10a, and PROMIS Global-10, including its physical and mental health subscales, at the same visit were identified. Spearman rho (ρ) correlations were calculated and ceiling and floor effects identified. Overall, 5,303 patient encounters were included. Among physical function domains, strong correlation existed between the KOOS-PS and PROMIS PF SF 10a (ρ = 0.76, P <.001), KOOS-PS and PROMIS Global Physical Health (ρ = 0.71, P <.001), and PROMIS PF SF 10a and PROMIS Global Physical Health (ρ = 0.78, P <.001). No physical function–focused PROM had an appreciable floor effect (ie, at or more than 1%). The KOOS-PS had a small but measurable ceiling effect (n = 105 [2.0%]). All of the examined PROMs are acceptable to measure the functional status of patients with knee pathology, with the PROMIS Global-10 also being able to capture elements of mental health too. The PROMIS Global-10 may be of most value of the PROMs assessed, as the United States Centers for Medicare and Medicaid Services already incorporate the mental health component into new alternative payment models. [ABSTRACT FROM AUTHOR]

Local control remains a vexing problem in the management of chordoma despite advances in operative techniques and radiotherapy (RT) protocols. Existing studies show satisfactory local control rates with different treatment modalities. However, those studies with minimum follow-up more than 4 years demonstrate increasing rates of local failure. Therefore, mid-term local survival rates may be inadvertently elevated by studies with less than 4 years follow-up. The purpose of this study is to report the mid-term results of primary spinal chordoma treated with en bloc resection and proton-based RT with minimum 5 years of follow-up. Retrospective, single-center, cohort study. Patients undergoing primary surgical excision of a spine or sacral chordoma tumor between 1990 and 2016 at a single-institution were included. Patients were included if they had a local failure at any time, or they had a minimum of 5 years of follow up with no local failure. Patients were excluded if a prior surgical excision was performed or metastases were present at the time of referral. The outcome measures were local recurrence-free interval (LRFI) and overall survival (OS). Demographic, clinical, oncologic and surgical variables, including margin status, as well as radiation doses and schedule (neoadjuvant, adjuvant, or both) were compared using Wilcoxon rank-sum or chi-squared testing. The goal RT dose was 70 Gray (total) and patients were stratified based on completing (C70) or receiving incomplete (I70) dosing. Overall survival (OS) and local-recurrence free interval (LRFI) were calculated using the Kaplan-Meier method. No funding was obtained for this work. Seventy-six patients were included in the final analysis. All patients had a minimum of 5-year follow-up (median 9.3 years, range 5.1–24.7 years). There were no significant clinical differences between the C70 and I70 RT groups. OS was greater for the C70 RT group (5-year OS 82% vs. 63%, p=.001). There was similar OS for the positive margin group (5-year OS 70% vs. 61%, p=.266). LRFI was greater for the C70 RT group (5-year OS 93% vs. 78%, p=.017). There was similar LRFI for the positive margin group (5-year OS 90% versus 87%, p=.810). Chordoma outcomes trend towards diminishing LRFI rates in the literature. Here we report the results of the operative management of primary spinal chordoma with minimum five year follow-up, the addition of C70 RT to surgical excision conferred a benefit to OS and local recurrence. [ABSTRACT FROM AUTHOR]

Background Context: Proximal junctional failure (PFJ) is a common and dreaded complication of adult spinal deformity. Previous research has identified parameters associated with the development of PJF and the search for radiographic and clinical variables continues in an effort to decrease the incidence of PFJ. The lordosis distribution index (LDI) is a parameter not based on pelvic incidence. Ideal values for LDI have been established in prior literature with demonstrated association with PJF.Purpose: The purpose of this study is compare PJF and mechanical failure rates between patients with ideal and nonideal LDI cohort.Study Design: This is a retrospective, single-center case-controlled study.Patient Sample: Adult patients who underwent surgical treatment for spinal deformity as defined by the SRS-Schwab criteria between 2001 and 2016 were included. Furthermore, fusion constructs spanned at least four vertebral segments with the upper instrumented vertebra (UIV) T9 or caudal. Patients who were under the age of 18, those with radiographic data less than 1 year, and those with neoplastic or trauma etiologies were excluded. Prior thoracolumbar spine surgery was not an exclusion criterion.Outcome Measures: The outcome measures were physiologic in nature: The primary outcome was defined as PFJ. The International Spine Study Group (ISSG) definition for PJF was used, which includes postoperative fracture of the UIV or UIV+1, instrumentation failure at UIV, PJA increase greater than 15° from preoperative baseline or extension of the construct needed within 6 months. Secondary outcomes included extension of the construct after 6 months or revision due to instrumentation failure, pseudarthrosis or distal junctional failure.Methods: A portion of this project was funded through National Institute of Health Grant 5UL1TR001067-05. The authors have no conflict of interest related to this study. The records of patients meeting the inclusion criteria were reviewed. Clinical and radiographic data were extracted and analyzed. Univariate cox proportional hazard models were used to identify factors associated with mechanical failure and included in a multivariate Cox proportional hazards model.Results: There were 187 patients that met the inclusion criteria. Univariate analysis demonstrated the number of levels fused, instrumentation to the sacrum or pelvis, PI-LL difference between pre- and postoperative states, T1-SPI, T9-SPI, and postoperative LDI (treated as a continuous variable). When LDI was treated as a categorical variable using an LDI cutoff of less than 0.5 for hypolordotic, 0.5 to 0.8 for aligned and greater than 0.8 for hyperlordotic, there was no difference in failure rates between the two groups.Conclusions: Lumbar lordosis is an important parameter in adult deformity. However, the LDI is an imperfect variable and previously developed categories did not show differences in failure rates in this cohort. [ABSTRACT FROM AUTHOR]

Abstract Objectives The purpose of this manuscript is to describe the origins of accountable care organizations and summarize their impact on spine care. Findings The unmitigated rise in capital expenditures for health care services in the latter half of the twentieth century gave rise to the development of cost-saving measures, including accountable care organizations. These have shown modest cost savings and improvements in quality measures but have largely ignored surgeons and surgical care. Conclusions As alternative payment models expand, spine surgery will be targeted for improvements. Spine surgeons should be involved in the structuring of those efforts. [ABSTRACT FROM AUTHOR]

Abstract Adjacent segment disease (ASD) is a known complication of lumbar spine arthrodesis and refers to any type of deterioration at the adjacent cephalad or caudad motion segment to a prior fusion. The existing literature points to a multifactorial etiology including alterations of the physiologic biomechanics after fusion as well as the intrinsic spondylosis present at the time of the index operation. Revision posterior laminectomy and fusion can be technically challenging and has a higher complication rate than primary decompression and fusion procedures. Lateral lumbar interbody fusion (LLIF) along with posterior extension of fusion in a hybrid technique provides a less invasive option for the surgical treatment of ASD. Adjacent level stenosis is addressed via indirect decompression of the central canal and foramina. In addition, an assortment of cages provides relative correction of coronal and sagittal plane deformity. This manuscript discusses the role of LLIF for the treatment of ASD and two illustrative cases are presented. [ABSTRACT FROM AUTHOR]

Laminoplasty is a motion-sparing decompression technique for the cervical spine. As the first description was published over 40 years ago, it has been established as an effective treatment for cervical spondylotic myelopathy. The application of this technique is predicated on maintenance of physiologic sagittal alignment in the cervical spine. Numerous variations of the originally published laminoplasty technique exist and they can be broadly categorized into symmetric or asymmetric canal expansions. Potential complications include chronic neck pain, C5 palsy, and door closure, among others. Recent clinical research suggests sparing the muscle attachments on the C2 and C7 spinous process may improve the incidence of pain. The purpose of this article is to review the indications and contraindications for cervical laminoplasty and evaluate its efficacy based on current literature. [ABSTRACT FROM AUTHOR]

Introduction The purpose of this study is to examine the clinical results of retrograde intramedullary headless screw (IMHS) fixation for metacarpal fractures. Methods A retrospective review was performed on 16 patients with 18 metacarpal fractures who underwent IMHS fixation at a single institution. The average age was 32 years. The indications for surgery included rotational malalignment (five patients), multiple metacarpal fractures (five patients), angular deformity (four patients), and shortening greater than 5 mm(two patients). The average length of follow-up was 19.4 weeks (median 10.2 weeks). Results Functional outcome was considered excellent in all patients with total active motion in excess of 240 degrees. Active motion was initiated within 1 week of surgery. No secondary surgeries were performed related to a complication of IMHS fixation. Conclusion IMHS fixation ofmetacarpal fractures is an efficacious treatmentmodality for patients with comminution, multiple fractures, malrotation, and those who require rapid mobilization. It obviates the need for immobilization or more extensive plate and screw fixation techniques with excellent clinical results. [ABSTRACT FROM AUTHOR]

Background: Limited health literacy exacerbates health inequity and has serious implications for patient care. It hinders successful communication and comprehension of relevant health information, which can lead to suboptimal care. Despite the evidence regarding the significance of health literacy, the topic has received little consideration in orthopedic spine patients.Purpose: To investigate the prevalence of- and factors associated with limited health literacy among outpatients presenting to a tertiary urban academic hospital-based orthopedic spine center.Study Design: Cross-sectionals.Patient Sample: Patients 18 years of age or older seen at a tertiary urban academic hospital-based multi-surgeon outpatient spine center.Outcome Measures: The Newest Vital Sign (NVS) health literacy assessment.Methods: Between December 2021 and March 2022, 447 consecutive English-speaking patients over the age of 18 years and new to the outpatient spine clinic were approached for participation in a cross-sectional survey study, of which 405 agreed to participate. Patients completed the Newest Vital Sign (NVS) health literacy assessment tool, the Rapid Estimation of Adult Literacy in Medicine Short Form (REALM-SF), and a sociodemographic survey (including race/ethnicity, level of education, employment status, income, and marital status). The NVS scores were divided into limited (0-3) and adequate (4-6) health literacy. REALM-SF scores were classified into reading levels below ninth grade (0-6) or at least ninth grade (7). Additional demographic data was extracted from patient records. Online mapping tools were used to collect the Social Vulnerability Index (SVI) and the Area Deprivation Index (ADI) for each patient. Subsequently, multivariable regression modeling was performed to identify independent factors associated with limited health literacy.Results: The prevalence of limited health literacy in patients presenting to an urban academic outpatient spine center was 33% (135/405). Unadjusted analysis found that patients who were socioeconomically disadvantaged (eg, unemployed, lower household income, publicly insured and higher SVI) and had more unfavorable social determinant of health features (eg, housing concerns, higher ADI, less years of education, below ninth grade reading level, unmarried) had high rates of limited health literacy. Adjusted regression analysis demonstrated that limited health literacy was independently associated with higher ADI state decile, living less than 10 years at current address, having housing concerns, not being employed, non-native English speaking, having less years of education and below ninth grade reading level.Conclusions: This study found that a substantial portion of the patients presenting to an outpatient spine center have limited health literacy, more so if they are socially disadvantaged. Future efforts should investigate the impact of limited health literacy on access to care, treatment outcomes and health care utilization in orthopedic patients. Neighborhood social vulnerability measures may be a feasible way to identify patients at risk of limited health literacy in clinical practice and offer opportunities for tailored patient care. This may contribute to prioritizing the mitigation of disparities and aid in the development of meaningful interventions to improve health equity in orthopedics. [ABSTRACT FROM AUTHOR]

Recently, a 2024 TSJ article by Shi et al. described the development of a machine learning (ML) model for predicting massive (>2500mL) intraoperative blood loss during posterior decompressive surgery for spinal metastasis. Surgery included en-bloc or partial resection of vertebrae with stabilization or palliative decompression with stabilization. The model was developed in a Chinese cohort (n = 200) and performed well in an external validation cohort (n = 76) within the same region. We sought to validate the ML model across two new geographical areas (North America and Europe) and patient cohorts. N/A N/A N/A N/A We retrospectively included patients across two institutions between 2016 and 2022. Inclusion and exclusion criteria were consistent with the development study, with additional inclusion of (1) patients undergoing palliative decompression without stabilization, (2) patients with multiple myeloma and lymphoma, and (3) patients who continued anticoagulants perioperatively. Massive intraoperative blood loss was defined as >2500mL and in addition to the Gross formula used in the development study, we quantified this outcome using 6 other methods as there is no gold standard for estimating blood loss. ML model predictions were compared against all intraoperative blood loss quantification methods. A sub-analysis, excluding the additional patient groups, assessed the ML model's performance with the same in- and exclusion criteria as the development cohort. Missing values were imputed using missForest in R. In total, 539 patients were included. There were notable differences in baseline characteristics between our cohort and the development cohort. We included more patients with partial or en-bloc resection, suggesting higher risk of blood loss, and lower Eastern Cooperative Oncology Group (ECOG) scores. However, depending on the method used, massive intraoperative blood loss incidence ranged from 7.7% (p <0.01) to 23% (p >0.999), which is less or equal to the development study respectively. The ML model scored poorly on performance metrics and overestimated the intraoperative blood loss across all outcome methods with the best performance using the Lopez-Picado nadir formula (specificity: 0.352, precision: 0.261), overall performance (F1 Score: 0.394, accuracy: 0.453, Brier score: 0.298, log loss: 0.848), and discriminatory ability (AUC: 0.634 [CI: 0.578, 0.690]), except for recall (0.875). Sub-analysis (n = 421) showed consistent poor performance. To our knowledge, this is the first external ML model validation within spine surgery demonstrating poor performance. The ML model displayed a strong tendency to overestimate massive intraoperative blood loss risk in our cohort. This overestimation might be attributed to a distributional shift as our cohort had key differences in variables used by the ML model to predict massive intraoperative blood loss, such as ECOG scores and surgery type. Overall, our results emphasize the importance of external validation and the development of ML algorithms in multiple geographical areas with varying baseline characteristic distributions, before implementing them in clinical practice. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

As value-based health care arrangements gain traction in spine care, understanding the true cost of care becomes critical. Historically, inaccurate cost proxies have been used, including negotiated reimbursement rates or list prices. However, time-driven activity-based costing (TDABC) allows for a more accurate cost assessment, including a better understanding of the primary drivers of cost in 1-level lumbar fusion. To determine the variation of total hospital cost, differences in characteristics between high-cost and nonhigh-cost patients, and to identify the primary drivers of total hospital cost in a sample of patients undergoing 1-level lumbar fusion. Retrospective, multicenter (one academic medical center, one community-based hospital), observational study. A total of 383 patients undergoing elective 1-level lumbar fusion for degenerative spine conditions between November 2, 2021 and December 2, 2022. Total hospital cost of care (normalized); preoperative, intraoperative, and postoperative cost of care (normalized); ratio of most to least expensive 1-level lumbar fusion. Patients undergoing a 1-level lumbar fusion between November 2, 2021 and December 2, 2022 were identified at two hospitals (one quaternary referral academic medical center and one community-based hospital) within our health system. TDABC was used to calculate total hospital cost, which was also broken up into: pre-, intra-, and postoperative timeframes. Operating surgeon and patient characteristics were also collected and compared between high- and nonhigh-cost patients. The correlation of surgical time and cost was determined. Multivariable linear regression was used to determine factors associated with total hospital cost. The most expensive 1-level lumbar fusion was 6.8x more expensive than the least expensive 1-level lumbar fusion, with the intraoperative period accounting for 88% of total cost. On average. the implant cost accounted for 30% of the total, but across the patient sample, the implant cost accounted for a range of 6% to 44% of the total cost. High-cost patients were younger (55 years [SD: 13 years] vs 63 years [SD: 13 years], p=.0002), more likely to have commercial health insurance (24 out of 38 (63%) vs 181 out of 345 (52%), p=.003). There was a poor correlation between time of surgery (ie, incision to close) and total overall cost (ρ:.26, p<.0001). Increase age (RC: -0.003 [95% CI: -0.006 to -0.000007], p=.049) was associated with decreased cost. Surgery by certain surgeons was associated with decreased total cost when accounting for other factors (p<.05). A large variation exists in the total hospital cost for patients undergoing 1-level lumbar fusion, which is primarily driven by surgeon-level decisions and preferences (eg, implant and technology use). Also, being a "fast" surgeon intraoperatively does not mean your total cost is meaningfully lower. As efforts continue to optimize patient value through ensuring appropriate clinical outcomes while also reducing cost, spine surgeons must use this knowledge to lead, or at least be active participants in, any discussions that could impact patient care. [ABSTRACT FROM AUTHOR]

Deep learning is increasingly impactful for healthcare research and delivery. In orthopaedics, there has been a significant increase in the number of publications using deep learning for interpreting radiographs; however, there are only a few applications of deep learning specific to spine surgery. In this review, we discuss the potential of deep learning within spine surgery in four contexts: diagnosis (1), prognosis (2), patient management (3) and integration with virtual/augmented reality, robotic surgery and biomedical wearables (4). Additionally, we discuss current literature, future potentials and provide takeaways for clinicians who wish to apply deep learning in their research and practice. [ABSTRACT FROM AUTHOR]

There is an increasing number of clinical prediction models in spine surgery based on machine learning. The purpose of this manuscript is to review 1) the outcomes they have focused on, 2) which models have been externally validated, and 3) how studies report their performance measures. Only 2 of 39 prediction models have been externally validated and complications were the most studied topics. Area under the curve (AUC) was the most frequently used performance measure, while calibration and decision-curve analysis are poorly reported. Future studies should focus on external validation of existing models. Publications on the development of models should include all fundamental performance measures and consider including a decision-curve analysis. [ABSTRACT FROM AUTHOR]

The risk factors for developing proximal junctional failure (PJF) after surgery for adult spinal deformity (ASD) continue to evolve. The lordosis distribution index (LDI) describes the amount of lower arc lordosis (L4-S1) as a fraction of total lumbar lordosis (L1-S1) and has been postulated to influence the outcomes of ASD. The purpose of this study is to determine if the LDI is a risk factor for mechanical failure after ASD. Retrospective review. Adult patients with ASD treated with thoracolumbar fusion (>4 levels, caudal to T9). Demographic variables and surgical data were recorded and radiographic data including proximal junctional angle (PJA), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), pelvic incidence (PI), T1 and T9 spinopelvic inclination (T1-SPI and T9-SPI), and LDI were calculated preoperatively, immediately postoperatively and at 6 months, 1 year and 2 years. Patients were categorized by LDI (severe hypolordosis, moderate hypolordosis, aligned and hyperlordosis) pre- and post-operatively along with the change in LDI between the two time points. Acute PJF (<6 months) was considered the primary outcome variable. Late failure was the secondary outcome measure and defined as PJF after 6 months of the index surgery, fracture of the upper instrumented vertebra (UIV) or UIV+1, rod fracture, non-union and distal junctional failure. There were 187 patients that met the inclusion criteria. Acute PJF occurred in 48 (25.6%) patients. At final follow up, 58 (31.0%) patients underwent surgery for acute PJF or late failure. There was no difference in the prevalence of acute PJF or late failure for patients that were severely hypolordotic (LDI<0.4), moderate hypolordotic (LDI 0.4 –0.49), aligned (LDI 0.5–0.8) or hyperlordotic (LDI>0.8) at the preoperative and immediate postoperative time points. Similarly, there was no difference in acute PJF or late failure when the amount of change in LDI was considered. Univariate cox proportional hazard models demonstrated the number of levels fused, exclusion of the sacrum and/or pelvis during instrumentation, postoperative change in PI-LL and T9-SPI were predictors of early or late failure. The lordosis distribution index is increasingly recognized as a relevant surgical variable in ASD treatment. This study sought to ascertain the association of LDI with mechanical failure. In this cohort of patients, the LDI did not impact the failure rate. However, this study corroborates previously known risk factors for failure including the number of levels fused, excluding the sacrum/pelvis, and amount of PI-LL mismatch correction. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Intraoperative neuromonitoring (IONM) is utilized during spine surgery to help prevent intraoperative neurologic injury. The first reported use of IONM in humans occurred more than four decades ago. Since its initial inception, technological advances such as the ability to monitor afferent sensory pathways and efferent motor pathways has greatly improved the efficiency and accuracy of IONM. Clinical research has established the superiority of multimodal IONM over unimodal techniques. However, controversy still exists regarding the most appropriate use of IONM. Currently, the surgeon is responsible for the interpretation of neuromonitoring alerts with the assistance of technicians and neurologists. Furthermore, the surgeon must determine the interventions necessary to mitigate neurologic risk according to such alerts. To that end, this chapter provides a historical context for IONM, reviews the physiologic mechanisms of common IONM modalities and examines the clinical evidence for IONM use. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Screening asymptomatic blunt trauma patients for cervical arterial injury is controversial. Vertebral artery injury (VAI) is most commonly associated with cervical spine fracture and some guidelines advocate indiscriminate screening of all cervical spine fractures. PURPOSE To determine whether the addition of computed tomography angiography (CT-A) resulted in a change in management for patients with cervical spine fractures. STUDY DESIGN/SETTING Propensity score matching cohort study. Participants of this study originated from two large academic trauma centers located in a single city. PATIENT SAMPLE Adult patients with acute cervical spine fractures sustained after blunt trauma between 2000 and 2015 were included. Patients with penetrating trauma, neoplasm and prior cervical spine surgery were excluded. There were 3,943 patients screened for inclusion and 2,831 patients eligible. OUTCOME MEASURES Recommendation for a change in management with antithrombosis was the primary outcome measure. Detection of stroke and vertebral artery injury were secondary outcomes. METHODS Demographic data, cervical spine fracture characteristics, utilization of CT-A, presence of vertebral artery injury and outcome were extracted from the medical record. Logistic regression identified factors associated with obtaining a CT-A. Propensity score matching was performed to negate the significant baseline characteristic differences including age, race, medical comorbidities, injury burden, mechanism of injury, upper cervical spine fracture, foramen transversarium involvement, multilevel involvement and associated facet dislocation. This resulted in one cohort receiving CT-A and one cohort that did not, both with 644 patients and equivalent demographic and clinical characteristics. The score matched patients who obtained CT-A with those who obtained CT alone to create two statistically equivalent cohorts. RESULTS In the matched cohorts, average age was 59 years and 57% of each cohort was male. CT-A identified definite or indeterminate VAI in 113 patients and 62 patients had antithrombosis recommended. In the cohort without CT-A, VAI was discovered in 11 patients incidentally through other imaging and eight were recommended antithrombosis. Two patients in the CT-A group had major adverse bleeding events as a result of antithrombosis initiation. There were no preventable strokes in either group. CONCLUSIONS The addition of CT-A increased the detection of VAI and antithrombosis recommendation. There was a high incidence of indeterminate CT-A findings. There were no preventable strokes in either cohort and two major adverse bleeding events as a result of recommended pharmacologic antithrombosis. Non-selective screening is not warranted and should be limited to a high-risk subset of patients. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Spinal conditions impact health-related quality of life (HRQoL). Patient education and counseling improve HRQoL, yet the effects may be limited for patients with inadequate health literacy (HL). Despite the established relationship between HRQoL and HL in other fields, research in the orthopedic spine population is lacking. To investigate if limited HL results in lower HRQoL and to evaluate factors are associated with HRQoL in patients seen at an outpatient orthopedic spine center. Prospective single-center cross-sectional study. Patients 18 years of age or older seen at a tertiary urban academic hospital- based multi-surgeon outpatient spine center. EQ-5D-5L health-related quality of life (HRQoL) questionnaire, and the Newest Vital Sign (NVS) HL assessment tool. Between October 2022 and February 2023, consecutive English-speaking patients over the age of 18 and new to the outpatient spine clinic were approached for participation in this cross-sectional survey study. Patients completed a sociodemographic survey, EQ-5D-5L HRQoL questionnaire, and Newest Vital Sign (NVS) HL assessment tool. The EQ-5D-5L yields two continuous outcomes: an index score ranging from below 0 to 1 and a visual analog scale (EQ-VAS) score ranging from 0 to 100. The NVS scores were divided into limited (0–3) and adequate (4–6) HL. Multivariate linear regression with purposeful selection of variables was performed to identify independent factors associated with HRQoL. Out of 397 eligible patients, 348 (88%) agreed to participate and were included in statistical analysis. Limited HL was independently associated with lower EQ-5D-5L index scores (B=1.07 [95% CI 1.00–1.15], p=.049. Other factors associated with lower EQ-5D-5L index scores were being obese (BMI≥30), having housing concerns, and being an active smoker. Factors associated with lower EQ-VAS scores were being underweight (BMI<18.5), obese, having housing concerns, and higher updated Charlson comorbidity index (uCCI) scores. Being married was associated with higher EQ-VAS scores. Limited HL is associated with lower EQ-5D-5L index scores in spine patients, indicating lower HRQoL. To effectively apply HL-related interventions in this population, a better understanding of the complex interactions between patient characteristics, social determinants of health, and HRQoL outcomes is required. Further research should focus on interventions to improve HRQoL in patients with limited HL and how to accurately identify these patients. Level II prognostic. [ABSTRACT FROM AUTHOR]

The opioid epidemic is a public health crisis causing significant morbidity, mortality and economic costs nationwide. As a result, discovering alternative forms of pain management is becoming imperative. Medical marijuana is an option for a nonopioid analgesic and is under investigation for potential uses in fields such as oncology and chronic pain, but it is yet to be studied in the surgical setting. Specifically, its effects on bone healing are not fully understood, significantly affecting its potential analgesic efficacy for postorthopaedic surgical care. The goal of this this study is to determine the effect of cannabis derivatives, D9-tetrahydrocannabinol (THC) and cannabidiol (CBD) on bone healing. The effects of marijuana on spinal arthrodesis specifically have yet to be investigated. We hypothesized that THC and CBD will not decrease bone healing in a rat model for spinal fusion. A basic science study utilizing a validated experimental model to assess spinal fusion performed on rats. N/A (Sprague-Dawley rats were used for this basic science study). Manual palpation was done to assess strength of the L4-L5 arthrodesis on all rats. Twelve rats underwent lumbar three-dimensional micro-computed tomography (μCT) imaging and histological analysis. The remaining half were subjected to quantitative polymerase chain reaction (qPCR) analyses which are currently pending. The μCT bone analysis was comprised of quantifying the ratio of bone volume (BV) to total volume (TV) within each volume of interest (VOI), as well as bone mineral density (BMD) and tissue mineral density (TMD) for the corresponding VOI. During follow-up, one animal from the saline and one from the combination group were lost due to wound dehiscence. Kruskal-Wallis test followed by Dunn's multiple comparisons test was performed using GraphPad Prism. Two-tailed values of p < 0.05 were considered statistically significant. Animal procedures were approved by the Institutional Animal Care and Use Committee (IACUC). Twenty-eight adult Sprague-Dawley rats were used for this study. Utilizing allogenic bone graft (4 donor rats), posterolateral inter-transverse lumbar fusion at the L4-L5 level was performed under surgical microscopy. The animals were divided into four groups of 6, each receiving 0.1ml intraperitoneal injections weekly as follows: placebo (saline), 5 mg/kg THC, 5 mg/kg CBD, and a combination of 5 mg/kg THC and 5 mg/kg CBD (combo). Eight weeks postsurgery, animals were euthanized and fusions were assessed. The combination treatment group had the highest fusion rates, with 66.7% demonstrating full fusion and 33.3% demonstrating partial fusion. This was followed by the THC group demonstrating 60% of rats with full fusion, 20% with partial fusion, and 20% with no fusion. Fusion rates were lower in the CBD and saline groups. However, the fusion rates were not significantly different between the treatment groups based on our manual palpation scoring. Callus formation was visually more extensive in THC and Combo treatments on μCT 3D reconstruction images. This observation was confirmed though μCT data, in which bone volume fraction (BV/TV) was significantly higher for the CBD and THC treatment groups compared to the saline treatment group (P <0.05). BMD and TMD values were higher for all cannabis treatment groups compared to the saline treatment group, though not statistically significant. This study preliminarily demonstrates that CBD and THC have no adverse effect on bone regeneration and rate of spinal fusion in rats. Cannabinoids may possess osteoinductive properties which require further investigation. Future larger animal studies should further investigate the effects of cannabinoid receptor agonists on bone healing and formation, with additional exploration of cannabinoid receptor agonists as a potential alternative approach to postoperative analgesia following spinal fusion and other procedures requiring bone formation. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Limited health literacy has previously been associated with increased health care utilization, worse general health status and self-reported health, and increased mortality. Identifying and accommodating patients with limited health literacy may offer an avenue towards mitigating adverse health outcomes and reduce unnecessary health care expenditure. Due to the challenges associated with implementation of lengthy health literacy assessments, the Brief Health Literacy Screening Instrument was developed. However, to our knowledge, there are no reports on the accuracy of this screening questionnaire, with or without the inclusion of sociodemographic characteristics, when predicting limited health literacy in orthopaedic spine patients. To evaluate the reliability and predictive accuracy of self-reported health literacy screening questions with and without the inclusion of sociodemographic variables in orthopaedic spine patients. Cross-sectional. Patients seen at a tertiary urban academic hospital-based multi-surgeon spine center Brief Health Literacy Screening Instrument (BRIEF), and the Newest Vital Sign (NVS) health literacy assessment tool. Between December 2021 and February 2022, consecutive English-speaking patients over the age of 18 presenting as new patients to an urban, hospital-based outpatient spine clinic were approached for participation. A sociodemographic survey, the BRIEF, and the NVS Health Literacy Assessment Tool were administered verbally. Simple and multivariable logistic regression was utilized to assess the accuracy of each BRIEF question individually, and collectively, at predicting limited health literacy as defined by the NVS. Further regression analysis included sociodemographic variables (age, body mass index, race, ethnicity, highest educational degree, employment status, marital status, annual household income, insurance status, and self-reported health. A total of 262 patients [mean age (years), 57 ± 17] were included in this study. One hundred thirty-four (51%) were male, 223 (85%) were White, and 151 (58%) were married. Patient BRIEF scores were as follows: 23 (9%) limited, 43 (16%) marginal, and 196 (75%) adequate. NVS scores identified 87 (33%) patients with possible limited health literacy. BRIEF items collectively demonstrated fair accuracy in the prediction of limited health literacy (area under the receiver operating characteristic curve, 0.76; 95% CI, 0.70−0.82). Individually, the fourth BRIEF item ("How confident are you in filling out medical forms by yourself?") was the best predictor of limited health literacy (area under the receiver operating characteristic curve, 0.67; 95% CI, 0.60−0.73). The predictive accuracy of the BRIEF items, both individually and collectively, increased with the inclusion of sociodemographic variables within the logistic regression. Specific characteristics independently associated with limited health literacy were self-identified Black race, retired or disabled employment status, single or divorced marital status, high school education or below, and self-reported "poor" health. Limited health literacy has implications for patient outcomes and health care costs. Our results show that the BRIEF questionnaire is a low-cost screening tool that demonstrates fair predictability in determining limited health literacy within a population of spine patients. Self-reported health literacy assessments may be more feasible in daily practice and easier to implement into clinical workflow. [ABSTRACT FROM AUTHOR]

Background Context: Historically, spine surgeons used expected postoperative survival of 3-months to help select candidates for operative intervention in spinal metastasis. However, this cutoff has been challenged by the development of minimally invasive techniques, novel biologics, and advanced radiotherapy. Recent studies have suggested that a life expectancy of 6 weeks may be enough to achieve significant improvements in postoperative health-related quality of life.Purpose: The purpose of this study was to develop a model capable of predicting 6-week mortality in patients with spinal metastases treated with radiation or surgery.Study Design/setting: A retrospective review was conducted at five large tertiary centers in the United States and Taiwan.Patient Sample: The development cohort consisted of 3,001 patients undergoing radiotherapy and/or surgery for spinal metastases from one institution. The validation institutional cohort consisted of 1,303 patients from four independent, external institutions.Outcome Measures: The primary outcome was 6-week mortality.Methods: Five models were considered to predict 6-week mortality, and the model with the best performance across discrimination, calibration, decision-curve analysis, and overall performance was integrated into an open access web-based application.Results: The most important variables for prediction of 6-week mortality were albumin, primary tumor histology, absolute lymphocyte, three or more spine metastasis, and ECOG score. The elastic-net penalized logistic model was chosen as the best performing model with AUC 0.84 on evaluation in the independent testing set. On external validation in the 1,303 patients from the four independent institutions, the model retained good discriminative ability with an area under the curve of 0.81. The model is available here: https://sorg-apps.shinyapps.io/spinemetssurvival/.Conclusions: While this study does not advocate for the use of a 6-week life expectancy as criteria for considering operative management, the algorithm developed and externally validated in this study may be helpful for preoperative planning, multidisciplinary management, and shared decision-making in spinal metastasis patients with shorter life expectancy. [ABSTRACT FROM AUTHOR]

Cervical sagittal alignment (CSA) parameters are helpful in determining the surgical technique used to treat cervical spondylotic myelopathy. Upright lateral radiographs are routinely used to measure CSA parameters, but obtaining adequate imaging is difficult. Utilizing magnetic resonance imaging (MRI) to evaluate sagittal parameters has been explored; however, the impact of positional changes on these parameters has not been elucidated. To evaluate CSA parameter measurement reliability and correlation between XR and MRI modalities in patients undergoing posterior decompressive procedures for cervical spondylotic myelopathy. Retrospective cohort study. We evaluated adult patients who had undergone laminoplasty or laminectomy and fusion for cervical spondylotic myelopathy between 2017 and 2019 and who had cervical spine XR and MRI within a 6-month timespan of one another. Outcomes of interest included intra- and interobserver reliability assessment of C2-C7 sagittal angle, C2-C7 sagittal vertical axis (SVA), and T1 tilt measurements as well as correlations in these parameters between imaging modalities. Two clinicians completed two independent rounds of C2-C7 sagittal angle, C2-C7 sagittal vertical axis (SVA), and T1 tilt measurements; intra- and interobserver reliability were assessed by intraclass correlation coefficient (ICC). Correlations between imaging modalities were analyzed using parametric and nonparametric statistical tests. Intra- and interobserver reliabilities were highly correlated with correlations greater than 0.85 across all permutations; ICCs were highest with MRI measurements. The C2-C7 sagittal angle was highly correlated between XR and MRI at 0.76 with no significant difference (p = 0.46). Weaker correlations existed for C2-C7 SVA (0.48) and T1 tilt (0.62) measurements with significant differences observed in the mean values between the two imaging modalities (p < 0.01). The C2-C7 sagittal angle is highly correlated and not significantly different between upright XR and supine MR images. However, cervical SVA and T1 tilt change with patient position. As MRI does not accurately reflect the CSA in the upright position, upright lateral radiographs should be obtained to assess global sagittal alignment when planning posterior based cervical fusions. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Background Context: Preoperative methicillin-resistant Staphylococcus aureus (MRSA) testing and decolonization has demonstrated success for arthroplasty patients in surgical site infections (SSIs) prevention. Spine surgery, however, has seen varied results.Purpose: The purpose of this study was to determine the impact of nasal MRSA testing and operative debridement rates on surgical site infection after primary lumbar fusion.Study Design/setting: Retrospective cohort study and/or Consolidated medical enterprise PATIENT SAMPLE: Adult patients undergoing primary instrumented lumbar fusions from January 2015 to December 2019 were reviewed.Outcome Measures: The primary outcome was incision and drainage performed in the operating room within 90 days of surgery.Methods: MRSA testing <90-day's before surgery, mupirocin prescription <30-day's before surgery, perioperative antibiotics, and Elixhauser comorbidity index were collected for each subject. Bivariate analysis used Wilcoxon rank-sum testing and logistic regression modeling Multivariable logistic regression modeling assessed for associations with MRSA testing, intravenous vancomycin use, and I&D rate.Results: The study included 1,884 patients for analysis, with mean age of 63.1 (SE 0.3) and BMI 29.5 (SE 0.1). MRSA testing was performed in 755 patients (40.1%) and was more likely to be performed in patients with lower Elixhauser index scores (OR 0.98, 95% CI 0.96-0.99, p=.021) on multivariable analysis. Vancomycin use increased significantly over time (OR 1.49 and/or year, 95% CI 1.3-1.8, p<.001) despite no change in mupirocin or I&D rates. MRSA testing, mupirocin prescriptions, perioperative parenteral vancomycin use, and intrawound vancomycin powder use had no impact on I&D rates. I&D risk was associated with higher BMI (OR 1.06, 95% CI 1.02-1.12, p=.009) and higher number of blood product units transfused (OR 1.23, 95% CI 1.03-1.46, p=.022).Conclusions: The present study demonstrates no impact on surgical I&D rates from the use of preoperative MRSA testing. Increased BMI and transfusions were associated with operative I&D rates for surgical site infection. As a result of the hospital directive, vancomycin use increased over time with no associated change in infection rates, underscoring the need for focused interventions, and engagement with antibiotic stewardship programs. [ABSTRACT FROM AUTHOR]

Background Context: We developed the New England Spinal Metastasis Score (NESMS) as a simple, informative, scoring scheme that could be applied to both operative and non-operative patients. The performance of the NESMS to other legacy scoring systems has not previously been compared using appropriately powered, prospectively collected, longitudinal data.Purpose: To compare the predictive capacity of the NESMS to the Tokuhashi, Tomita and Spinal Instability Neoplastic Score (SINS) in a prospective cohort, where all scores were assigned at the time of baseline enrollment.Patient Sample: We enrolled 202 patients with spinal metastases who met inclusion criteria between 2017-2019.Outcome Measures: One-year survival (primary); 3-month mortality and ambulatory function at 3- and 6-months were considered secondarily.Methods: All prognostic scores were assigned based on enrollment data, which was also assigned as time-zero. Patients were followed until death or survival at 365 days after enrollment. Survival was assessed using Kaplan-Meier curves and score performance was determined via logistic regression testing and observed to expected plots. The discriminative capacity (c-statistic) of the scoring measures were compared via the z-score.Results: When comparing the discriminative capacity of the predictive scores, the NESMS had the highest c-statistic (0.79), followed by the Tomita (0.69), the Tokuhashi (0.67) and the SINS (0.54). The discriminative capacity of the NESMS was significantly greater (p-value range: 0.02 to <0.001) than any of the other predictive tools. The NESMS was also able to inform independent ambulatory function at 3- and 6-months, a function that was only uniformly replicated by the Tokuhashi score.Conclusions: The results of this prospective validation study indicate that the NESMS was able to differentiate survival to a significantly higher degree than the Tokuhashi, Tomita and SINS. We believe that these findings endorse the utilization of the NESMS as a prognostic tool capable of informing care for patients with spinal metastases. [ABSTRACT FROM AUTHOR]

Background: Intraoperative vascular injury (VI) may be an unavoidable complication of anterior lumbar spine surgery; however, vascular injury has implications for quality and safety reporting as this intraoperative complication may result in serious bleeding, thrombosis, and postoperative stricture.Purpose: The purpose of this study was to (1) develop machine learning algorithms for preoperative prediction of VI and (2) develop natural language processing (NLP) algorithms for automated surveillance of intraoperative VI from free-text operative notes.Patient Sample: Adult patients, 18 years or age or older, undergoing anterior lumbar spine surgery at two academic and three community medical centers were included in this analysis.Outcome Measures: The primary outcome was unintended VI during anterior lumbar spine surgery.Methods: Manual review of free-text operative notes was used to identify patients who had unintended VI. The available population was split into training and testing cohorts. Five machine learning algorithms were developed for preoperative prediction of VI. An NLP algorithm was trained for automated detection of intraoperative VI from free-text operative notes. Performance of the NLP algorithm was compared to current procedural terminology and international classification of diseases codes.Results: In all, 1035 patients underwent anterior lumbar spine surgery and the rate of intraoperative VI was 7.2% (n=75). Variables used for preoperative prediction of VI were age, male sex, body mass index, diabetes, L4-L5 exposure, and surgery for infection (discitis, osteomyelitis). The best performing machine learning algorithm achieved c-statistic of 0.73 for preoperative prediction of VI (https://sorg-apps.shinyapps.io/lumbar_vascular_injury/). For automated detection of intraoperative VI from free-text notes, the NLP algorithm achieved c-statistic of 0.92. The NLP algorithm identified 18 of the 21 patients (sensitivity 0.86) who had a VI whereas current procedural terminologyand international classification of diseases codes identified 6 of the 21 (sensitivity 0.29) patients. At this threshold, the NLP algorithm had a specificity of 0.93, negative predictive value of 0.99, positive predictive value of 0.51, and F1-score of 0.64.Conclusion: Relying on administrative procedural and diagnosis codes may underestimate the rate of unintended intraoperative VI in anterior lumbar spine surgery. External and prospective validation of the algorithms presented here may improve quality and safety reporting. [ABSTRACT FROM AUTHOR]

Background Content: Cervical laminoplasty (LP) and laminectomy and fusion (LF) are commonly used surgical techniques for cervical spondylotic myelopathy (CSM). Several recent studies have demonstrated superior perioperative metrics and decreased overall costs with LP, yet LF is performed far more often in the United States.Purpose: To determine the percentage of patients with CSM who are radiographically candidates for LP.Study Design: Retrospective comparative cohort study.Patient Sample: Patients >18 years old who underwent LF or LP for CSM at 2 large academic institutions from 2017 to 2019.Outcome Measures: Candidacy for LP based on radiographic criteria.Methods: Radiographs were assessed by 2 spine surgeons not involved in the care of the patients to determine the C2-C7 Cobb angle and the presence and extent of cervical instability. Patients with kyphosis >13°, > 3.5 mm of listhesis on static imaging, or > 2.5 mm of motion on flexion-extension or standing-supine films were not considered candidates for LP. Intraclass coefficient (ICC) was calculated to assess the interobserver reliability of angular measurements and the presence of instability. The percentage of patients for whom LP was contraindicated was calculated.Results: One hundred eight patients underwent LF while 142 underwent LP. Of the 108 patients who underwent LF, 79.6% were radiographically deemed candidates for LP, as were all 142 patients who underwent LP. The ICC for C2-C7 alignment was 0.90; there was 97% agreement with respect to the presence of instability.Conclusions: In 250 patients with CSM, 228 (91.2%) were radiographically candidates for LP. These data suggest that LP may be an underutilized procedure for the treatment for CSM. [ABSTRACT FROM AUTHOR]

Background: The ability to preoperatively predict which patients will achieve a minimal clinically important difference (MCID) after lumbar spine decompression surgery can help determine the appropriateness and timing of surgery. Patient-Reported Outcome Measurement Information System (PROMIS) scores are an increasingly popular outcome instrument.Purpose: The purpose of this study was to develop algorithms predictive of achieving MCID after primary lumbar decompression surgery.Patient Sample: This was a retrospective study at two academic medical centers and three community medical centers including adult patients 18 years or older undergoing one or two level posterior decompression for lumbar disc herniation or lumbar spinal stenosis between January 1, 2016 and April 1, 2019.Outcome Measures: The primary outcome, MCID, was defined using distribution-based methods as one half the standard deviation of postoperative patient-reported outcomes (PROMIS physical function, pain interference, pain intensity).Methods: Five machine learning algorithms were developed to predict MCID on these surveys and assessed by discrimination, calibration, Brier score, and decision curve analysis. The final model was incorporated into an open access digital application.Results: Overall, 906 patients completed at least one PROMs survey in the 90 days before surgery and at least one PROMs survey in the year after surgery. Attainment of MCID during the study period by PROMIS instrument was 74.3% for physical function, 75.8% for pain interference, and 79.2% for pain intensity. Factors identified for preoperative prediction of MCID attainment on these outcomes included preoperative PROs, percent unemployment in neighborhood of residence, comorbidities, body mass index, private insurance, preoperative opioid use, surgery for disc herniation, and federal poverty level in neighborhood of residence. The discrimination (c-statistic) of the final algorithms for these outcomes was 0.79 for physical function, 0.74 for pain interference, and 0.69 for pain intensity with good calibration. The open access digital application for these algorithms can be found here: https://sorg-apps.shinyapps.io/promis_pld_mcid/ CONCLUSION: Lower preoperative PROMIS scores, fewer comorbidities, and certain sociodemographic factors increase the likelihood of achieving MCID for PROMIS after lumbar spine decompression. [ABSTRACT FROM AUTHOR]

Background Context: Patient-Reported Outcome Measurement Information System (PROMIS) scores are increasingly utilized in clinical care. However, it is unclear if PROMIS can discriminate surgeon performance on an individual level.Purpose: The purpose of this study was to examine surgeon-level variance in rates of achieving minimal clinically important difference (MCID) after lumbar decompression.Patient Sample: This is a prospective, observational cohort study performed across a healthcare enterprise (two academic medical centers and three community centers). Patients 18 years or older undergoing one- to two-level primary decompression for lumbar disc herniation (LDH) or lumbar spinal stenosis (LSS) were included.Outcome Measures: The primary outcome was achievement of MCID, using a distribution-based method, on paired PROMIS physical function scores.Methods: Descriptive statistics were generated to examine the baseline characteristics of the study cohort. Bivariate analyses were used to examine the impact of surgeon-level variance on rates of MCID. Multivariable analyses were used to examine the risk-adjusted impact of surgeon-level variance on rates of MCID.Results: Overall, 636 patients treated by nine surgeons were included. The median patient age was 58 [interquartile range (IQR): 46-70] and 62.3% (n=396) were female. Among all patients, 56.9% (n=362) underwent surgery for LDH. The overall rate of achieving MCID was 75.8% (n=482). Of the surgeons, the median years in practice were 12 (range 4-31) and 55.6% (n=5) were in academic practice settings. On bivariate analysis, patients treated by one of the surgeons had lower rates of achieving MICD (odds ratio=0.37, 95% confidence interval: 0.15-0.91, p=.03). However, on multivariable analysis adjusting for operative indication (LDH vs. LSS), body mass index, number of comorbidities, percent unemployment in patient zip code, and preoperative PROMIS physical function scores, all surgeons were equally likely to obtain MCID.Conclusions: In this cohort, variance in PROMIS scores after primary lumbar decompression is influenced by patient-related factors and not by individual surgeon. Adequate risk adjustment is needed if ascertaining clinical improvement on an individual surgeon basis.Level Of Evidence: 2. [ABSTRACT FROM AUTHOR]

Background Context: The New England Spinal Metastasis Score (NESMS) was proposed as an intuitive and accessible prognostic tool for predicting survival in patients with spinal metastases. We designed an appropriately powered, prospective, longitudinal investigation to validate the NESMS.Purpose: To prospectively validate the NESMS.Study Design: Prospective longitudinal observational cohort study.Patient Sample: Patients, aged 18 and older, presenting for treatment with spinal metastatic disease.Outcome Measures: One-year mortality (primary); 6-month mortality and mortality at any time point following enrollment (secondary).Methods: The date of enrollment was set as time zero for all patients. The NESMS was assigned based on data collected at the time of enrollment. Patients were prospectively followed to one of two predetermined end-points: death, or survival at 365 days following enrollment. Survival was visually assessed with Kaplan-Meier curves and then analyzed using multivariable logistic regression, followed by Bayesian regression to assess for robustness of point estimates and 95% confidence intervals (CI).Results: This study included 180 patients enrolled between 2017 and 2018. Mortality within 1-year occurred in 56% of the cohort. Using NESMS 3 as the referent, those with a score of 2 had significantly greater odds of mortality (odds ratio 7.04; 95% CI 2.47, 20.08), as did those with a score of 1 (odds ratio 31.30; 95% CI 8.82, 111.04). A NESMS score of 0 was associated with perfect prediction, as 100% of individuals with this score were deceased at 1-year. Similar determinations were encountered for mortality at 6-months and overall.Conclusions: This study validates the NESMS and demonstrates its utility in prognosticating survival for patients with spinal metastatic disease, irrespective of selected treatment strategy. This is the first study to prospectively validate a prognostic utility for patients with spinal metastases. The NESMS can be directly applied to patient care, hospital-based practice and health-care policy. [ABSTRACT FROM AUTHOR]

Background Context: Laminectomy with fusion (LF) and laminoplasty (LP) are commonly used to treat cervical spondylotic myelopathy (CSM). The decision regarding which procedure to perform is largely a matter of surgeon's preference, while financial implications are rarely considered.Purpose: We aimed to better understand the financial considerations of LF compared to LP in the treatment of CSM.Study Design: Retrospective comparative study.Patient Sample: Adult patients, 18 years of age or older, who had undergone LF or LP for CSM from 2017 to 2019 at 2 large academic centers were included. Patients who had undergone previous cervical spine surgery or procedures that extended above C2 or below T2 were excluded.Outcome Measures: The primary outcome was defined as the total cost of the procedure, which was calculated as the sum of the implant and non-implant supply costs.Methods: Patient demographics, surgical parameters, including estimated blood loss and operative time, and length of stay were collected. Operating room material - both implant and non-implant - cost data was also obtained. Variables were analyzed individually as well as after adjustment based on the number of operative levels involved. Statistical analysis was performed using either Student t test with unequal variance or Wilcoxon rank sum test for continuous variables and chi-squared analysis for categorical variables.Results: Two hundred fifty patients were identified who met inclusion criteria. There was no statistical difference in the mean age at time of surgery (p=.25), gender distribution (p=.33), or re-operation rate between the LF and LP groups (p=.39). Overall, operative time was similar between the LF (165.7 ± 61.9 min) and LP (173.8 ± 58.2 min) groups (p=.29), but the LP cohort had a shorter length of stay at 3.8 ± 2.7 days compared to the LF cohort at 4.8 ± 3.7 days. Implant costs in the LF group were significantly more at $6,204.94 ± $1426.41 compared to LP implant costs at $1994.39 ± $643.09. Mean total costs of LP were significantly less at $2,859.08 ± $784.19 compared to LF total costs of $6,983.16 ± $1,589.17. Furthermore, when adjusted for the number of operative levels, LP remained significantly less costly at $766.12 ± $213.64 per level while LF cost $1,789.05 ± $486.66 per operative level. Additional subgroup analysis limiting the cohorts to patients with either three or four involved vertebral levels demonstrated nearly identical cost savings with LP as compared to LF.Conclusions: This study demonstrates that LF is on average at least 2.4 times the total operative supply cost of LP and at least 2.3 times the operative supply cost of LP when adjusted for the number of operative levels. In patients deemed appropriate for either LP or LF, these data may be incorporated into decision-making for the treatment of CSM. [ABSTRACT FROM AUTHOR]

Background: Surgical site infections are a major driver of morbidity and increased costs in the postoperative period after spine surgery. Current tools for surveillance of these adverse events rely on prospective clinical tracking, manual retrospective chart review, or administrative procedural and diagnosis codes.Purpose: The purpose of this study was to develop natural language processing (NLP) algorithms for automated reporting of postoperative wound infection requiring reoperation after lumbar discectomy.Patient Sample: Adult patients undergoing discectomy at two academic and three community medical centers between January 1, 2000 and July 31, 2019 for lumbar disc herniation.Outcome Measures: Reoperation for wound infection within 90 days after surgery METHODS: Free-text notes of patients who underwent surgery from January 1, 2000 to December 31, 2015 were used for algorithm training. Free-text notes of patients who underwent surgery after January 1, 2016 were used for algorithm testing. Manual chart review was used to label which patients had reoperation for wound infection. An extreme gradient-boosting NLP algorithm was developed to detect reoperation for postoperative wound infection.Results: Overall, 5,860 patients were included in this study and 62 (1.1%) had a reoperation for wound infection. In patients who underwent surgery after January 1, 2016 (n=1,377), the NLP algorithm detected 15 of the 16 patients (sensitivity=0.94) who had reoperation for infection. In comparison, current procedural terminology and international classification of disease codes detected 12 of these 16 patients (sensitivity=0.75). At a threshold of 0.05, the NLP algorithm had positive predictive value of 0.83 and F1-score of 0.88.Conclusion: Temporal validation of the algorithm developed in this study demonstrates a proof-of-concept application of NLP for automated reporting of adverse events after spine surgery. Adapting this methodology for other procedures and outcomes in spine and orthopedics has the potential to dramatically improve and automatize quality and safety reporting. [ABSTRACT FROM AUTHOR]

Importance: Preoperative determination of the potential for postoperative opioid dependence in previously naïve patients undergoing elective spine surgery may facilitate targeted interventions.Objective: The purpose of this study was to develop supervised machine learning algorithms for preoperative prediction of prolonged opioid prescription use in opioid-naïve patients following lumbar spine surgery.Design: Retrospective review of clinical registry data. Variables considered for prediction included demographics, insurance status, preoperative medications, surgical factors, laboratory values, comorbidities, and neighborhood characteristics. Five supervised machine learning algorithms were developed and assessed by discrimination, calibration, Brier score, and decision curve analysis.Setting: One healthcare entity (two academic medical centers, three community hospitals), 2000 to 2018.Participants: Opioid-naïve patients undergoing decompression and/or fusion for lumbar disk herniation, stenosis, and spondylolisthesis.Main Outcome: Sustained prescription opioid use exceeding 90 days after surgery.Results: Overall, of 8,435 patients included, 359 (4.3%) were found to have prolonged postoperative opioid prescriptions. The elastic-net penalized logistic regression achieved the best performance in the independent testing set not used for algorithm development with c-statistic=0.70, calibration intercept=0.06, calibration slope=1.02, and Brier score=0.039. The five most important factors for prolonged opioid prescriptions were use of instrumented spinal fusion, preoperative benzodiazepine use, preoperative antidepressant use, preoperative gabapentin use, and uninsured status. Individual patient-level explanations were provided for the algorithm predictions and the algorithms were incorporated into an open access digital application available here: https://sorg-apps.shinyapps.io/lumbaropioidnaive/.Conclusion and Relevance: The clinician decision aid developed in this study may be helpful to preoperatively risk-stratify opioid-naïve patients undergoing lumbar spine surgery. The tool demonstrates moderate discriminative capacity for identifying those at greatest risk of prolonged prescription opioid use. External validation is required to further support the potential utility of this tool in practice. [ABSTRACT FROM AUTHOR]

Background: Incidental durotomy is a common intraoperative complication during spine surgery with potential implications for postoperative recovery, patient-reported outcomes, length of stay, and costs. To our knowledge, there are no processes available for automated surveillance of incidental durotomy.Purpose: The purpose of this study was to develop natural language processing (NLP) algorithms for automated detection of incidental durotomies in free-text operative notes of patients undergoing lumbar spine surgery.Patient Sample: Adult patients 18 years or older undergoing lumbar spine surgery between January 1, 2000 and June 31, 2018 at two academic and three community medical centers.Outcome Measures: The primary outcome was defined as intraoperative durotomy recorded in free-text operative notes.Methods: An 80:20 stratified split was undertaken to create training and testing populations. An extreme gradient-boosting NLP algorithm was developed to detect incidental durotomy. Discrimination was assessed via area under receiver-operating curve (AUC-ROC), precision-recall curve, and Brier score. Performance of this algorithm was compared with current procedural terminology (CPT) and international classification of diseases (ICD) codes for durotomy.Results: Overall, 1,000 patients were included in the study and 93 (9.3%) had a recorded incidental durotomy in the free-text operative report. In the independent testing set (n=200) not used for model development, the NLP algorithm achieved AUC-ROC of 0.99 for detection of durotomy. In comparison, the CPT/ICD codes had AUC-ROC of 0.64. In the testing set, the NLP algorithm detected 16 of 18 patients with incidental durotomy (sensitivity 0.89) whereas the CPT and ICD codes detected 5 of 18 (sensitivity 0.28). At a threshold of 0.05, the NLP algorithm had specificity of 0.99, positive predictive value of 0.89, and negative predictive value of 0.99.Conclusions: Internal validation of the NLP algorithm developed in this study indicates promising results for future NLP applications in spine surgery. Pending external validation, the NLP algorithm developed in this study may be used by entities including national spine registries or hospital quality and safety departments to automate tracking of incidental durotomies. [ABSTRACT FROM AUTHOR]

There is a growing focus on reigning in costs while simultaneously optimizing patient outcomes via a value-based health care (VBHC) transformation. To date, the true cost of care has not been well delineated and many proxies for cost (eg, negotiated reimbursement rates) have been used but are inaccurate and not comprehensive. More robust cost analysis can be done using time-driven activity-based costing (TDABC), a well-documented approach out of Harvard Business School to accurately measure costs. 1) To determine the variation of total cost in 1- or 2- level lumbosacral decompression and fusion surgery and the breakdown of total cost by pre-, intra-, and postoperative care; 2) To determine differences in characteristics between high-cost (top decile) and non-high cost lumbosacral decompression surgeries; 3) To determine the primary cost drivers of 1- or 2-level lumbosacral decompression surgery. Multicenter (one quaternary referral academic medical center and one community hospital) economic analysis. A total of 405 patients who underwent primary 1- or 2-level lumbosacral decompression surgery between November 2, 2021 and December 2, 2022. Variation in total cost, differences between high- and non-high cost patients, and main drivers of total cost (broken down into pre-, intra-, and postoperative cost), as calculated using TDABC. Patients undergoing primary 1- or 2-level lumbosacral decompression and fusion surgery were identified from our institutional database. TDABC methodology was used to calculate total cost. The episode of care was defined as three phases: pre-, intra-, and postoperative. Patient and surgery-related characteristics were identified. To abide by institutional requirements, total cost was normalized to a mean of 1. The variation of total cost was assessed by looking at the most and least expensive total cost. Consistent with prior literature, high cost patients were defined as being in the top decile and a comparison of all factors were made between them and non-high cost patients. Multivariable linear regression was used to identify factors associated with total cost. The highest total cost for a 1- or 2-level lumbosacral decompression and fusion surgery was 9.5x the lowest total cost. On average, intraoperative cost accounted for 87% of the total cost of care. Overall, the hardware itself accounted for 30% of the total cost of care; however, this ranged from 6% to 44% of the total cost of care. High cost patients more often had commercial insurance (n=25 [63%] versus n=190 [52%], p=0.007). When accounting for all other factors, length of stay was associated with increased cost (Regression Coefficient [RC]: 0.02 (95% CI: 0.003 to 0.04), p=0.02). Outpatient surgery (RC: -0.10 (95% CI: -0.18 to -0.01), p=0.027) and multiple surgeons (Surgeons 2, 3, 5, 6, 7, 9, 11, 13, 14, and 15; all p<0.05) were associated with decreased total cost. A wide variation (9.5x difference) in total cost for primary 1- or 2-level lumbosacral decompression and fusion exists. In addition, this study confirms that just under 90% of the total cost is driven by the intraoperative cost, with the large majority being the hardware and technology. Thus, for the same indications, this wide variation in total cost appears to be driven by surgeon preference and idiosyncrasy. Spine surgeons should appreciate these findings and help lead discussions around initiatives and innovations to reduce cost, while also optimizing patient outcomes as part of the VBHC transformation This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Preoperative MRSA screening and decolonization has demonstrated success for some orthopaedic subspecialties in prevention of surgical site infections (SSIs). Spine surgery, however, has seen varied results, potentially secondary to the anatomic and surgical heterogeneity of the patients included in prior studies. Given that prior research has demonstrated greater propensity for gram positive SSIs in the cervical spine, we sought to investigate if MRSA screening would be more impactful in the cervical spine. The purpose of this study was to determine the relationship between nasal MRSA testing and SSI rates specifically in the setting of primary posterior cervical instrumented spine surgery. Retrospective cohort study. Adult patients undergoing primary instrumented posterior cervical procedures from January 2015-December 2019 at two tertiary academic referral centers in an urban setting Physiologic measures: subfascial presumed infected collection or abscess within 90 days of the index operation. Adult patients undergoing primary instrumented posterior cervical procedures from January 2015-December 2019 were reviewed for MRSA testing < 90-days before surgery, preoperative mupirocin, perioperative antibiotics and SSI defined as operative incision and drainage (I&D) < 90-days after surgery. Trauma, tumor and infection cases were excluded. Logistic regression modeling was used with SSI the primary outcome and MRSA screening the primary predictor with clinical and demographic factors as covariates. This study included 668 patients, of whom MRSA testing was performed in 212 patients (31.7%) and 6 (2.8%) were colonized with MRSA. Twelve patients (1.8%) underwent an I&D. On adjusted analysis, preoperative MRSA testing was not associated with postoperative I&D risk. Perioperative vancomycin similarly had no association with postoperative I&D risk. Notably, six patients (50%) grew MSSA from intraoperative cultures, with no cases of MRSA. There was no association between preoperative nasal MRSA screening and SSIs in primary posterior cervical instrumented procedures, nor was there any association between vancomycin or infection rate. Furthermore, there was a preponderance of gram-positive infections but none caused by MRSA. Given these findings, the considerable cost and effort associated with MRSA testing in the setting of primary posterior cervical instrumentation may not be justified. Further research should investigate if higher-risk scenarios demonstrate greater utility of preoperative testing. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Historically, spine surgeons used expected postoperative survival of three months to help select candidates for operative intervention in spinal metastasis. However, this cutoff has been challenged by the development of minimally invasive techniques, novel biologics and advanced radiotherapy. Recent studies have suggested that life expectancy of six weeks may be enough to achieve significant improvements in postoperative health-related quality of life. The purpose of this study was to develop a model capable of predicting six-week mortality in patients with spinal metastases treated with radiation or surgery. Retrospective review was conducted at five large tertiary centers in the United States and Taiwan. The development cohort consisted of 3,001 patients undergoing radiotherapy and/or surgery for spinal metastases from one institution. The validation institutional cohort consisted of 1,303 patients from four independent, external institutions. The primary outcome was six-week mortality. Five models were considered to predict six-week mortality, and the model with the best performance across discrimination, calibration, decision-curve analysis and overall performance was integrated into an open access web-based application. The most important variables for prediction of six-week mortality were albumin, primary tumor histology, absolute lymphocyte, three or more spine metastasis, and ECOG score. The elastic-net penalized logistic model was chosen as the best performing model with AUC 0.84 on evaluation in the independent testing set. On external validation in the 1,303 patients from the four independent institutions, the model retained good discriminative ability with an area under the curve of 0.81. As spinal metastasis patients with shorter life expectancy are considered for operative intervention, the algorithm developed and externally validated in this study may be helpful for preoperative planning, multidisciplinary management, and shared decision-making. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Spinal injuries are relatively common injuries that have a lasting impact on patients and are a significant cause of disability. Gunshot induced spinal injuries (GSIs) are the third most common cause of spinal injury and are increasing in proportion. Despite the severity and frequency of these injuries, there remains a lack of conclusive evidence regarding the optimal management of patients with GSIs. We aimed to better understand the impact of surgical intervention in patients who sustained gunshot induced spinal injuries. Retrospective comparative study. Patients in the National Spinal Cord Injury Statistical Center (NSCISC) database with GSIs and complete one-year follow-up information. (n = 961) The primary outcome measure was defined as improvement in ASIA Impairment Scale from the time of presentation. Patient demographics, clinical information, and outcome data were extracted from the NSCISC database. Surgical intervention was defined as any procedure involving a laminectomy, neural canal restoration, open reduction, spinal fusion, or internal fixation of the spine. Functional assessments included the American Spinal Injury Association (ASIA) Impairment scale. Bivariate analysis as well as multivariate analysis was performed. A total of 961 patients with GSI and one-year follow-up were identified from 1975-2016. The majority of patients were Black/African American (55.6%), male (89.7%), and aged 15-29 (73.8%). Of those who underwent surgical intervention, 34.2% had an improvement in their ASIA Impairment Scale at one year as compared to 20.6% of those treated non-operatively. Overall, surgery was associated with 2.0 [95% CI 1.4 - 2.8] times greater likelihood of ASIA Impairment Scale improvement at one year. Specifically, benefit was seen in thoracic (OR 2.5 [95% CI 1.4-4.6]) and lumbar injuries (OR 1.7 [95% CI 1.1-3.1]), but not cervical injuries. At 5-year follow-up, surgery was associated with 6.2 [95% CI 1.4-16.0] times greater likelihood of improvement in the ASIA Impairment Scale. While the decision to undergo surgery should be individualized, in our large review of GSIs, surgical intervention was associated with a greater likelihood of neurologic recovery. Specifically, patients with thoracic and lumbar GSI have a 2.5- and 1.7-times, respectively, greater likelihood of improvement in their ASIA Impairment Scale one year after injury if they underwent surgical intervention. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Surgical site infections (SSI) constitute significant morbidity in spine surgery. Efforts at SSI prevention include preoperative methicillin-resistant Staphylococcus aureus (MRSA) screening and decolonization, with demonstrated success for arthroplasty patients along with vascular and cardiothoracic surgical patients. The variety of surgical approaches and anatomic regions within spine surgery can limit the impact of analyses at the subspecialty level. Despite the success of MRSA nasal screening and decolonization in reducing SSI rates in other disciplines, the impact on spine surgery is less understood. To determine the relationship between nasal MRSA testing and operative debridement rates for surgical site infection after primary lumbar fusion. Retrospective cohort study at two academic tertiary referral centers. Adult patients (>18 years) were identified from January 2015 to March 2020 based on CPT codes for spinal instrumentation and fusion. Inclusion criteria were primary instrumented posterior lumbar fusion between 1-3 levels and exclusion criteria were revision surgery, tumor, infection, lateral-only surgery or operative surgeon with fewer than 20 cases. Operative incision and drainage (I&D) of the index lumbar spine wound within 90-days after surgery was the primary outcome. Chart text, operative reports and laboratory reports were reviewed for data abstraction. Multivariable logistic regression modeling assessed for demographic differences between MRSA testing groups as well as factors contributing to I&D risk. There were 2,148 patients included with a mean age 62.5 (SD 12.9), 56.9% female, and mean BMI 29.4 (SD 6.2). MRSA testing 90 days prior to surgery was completed in 884 (41.1%) of patients, and 19 (2.2%) of tested patients were colonized with MRSA preoperatively. Thirty-six (1.7%) patients underwent surgical I&D within 90 days of their index procedure for a surgical site infection. I&D risk was not associated with presence or result of MRSA testing, preoperative mupirocin prescriptions, or type of intraoperative antibiotic after controlling for surgeon. I&D risk was associated with higher BMI (5.7% increased risk for every 1 unit increase in BMI or a coefficient of 0.057, 95% confidence interval 0.017 to 0.097, p = 0.005) after controlling for age, diabetes and smoking status. The present study demonstrates no difference in surgical I&D rates between patients who underwent MRSA testing, who had positive MRSA colonization or who underwent other interventions aimed at decreasing SSI rates such as preoperative mupirocin decolonization or addition of intraoperative vancomycin. Increased BMI was associated with risk of undergoing an operative I&D for surgical site infection, suggesting that patient factors dominate over clinical interventions in the prevention of surgical site infection after primary lumbar spine fusion. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]