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Symptomatic postoperative epidural hematomas are rare, with an incidence of 0.10% to 0.69%. Risk factors have varied in the literature, but multiple studies have reported advanced age, preoperative or postoperative coagulopathy, and multilevel laminectomy as risk factors for hematoma. The role of pharmacologic anticoagulation after spine surgery remains unclear, but multiple studies suggest it can be done safely with a low risk of epidural hematoma. Prophylactic suction drains have not been found to lower hematoma incidence. Most symptomatic postoperative epidural hematomas present within the first 24 to 48 hours after surgery but can present later. Diagnosis of a symptomatic hematoma requires correlation of clinical signs and symptoms with a compressive hematoma on MRI. Patients will usually first complain of a marked increase in axial pain, followed by radicular symptoms in the extremities, followed by motor weakness and sphincter dysfunction. An MRI should be obtained emergently, and if it confirms a compressive hematoma, surgical evacuation should be carried out as quickly as possible. The prognosis for neurologic improvement after evacuation depends on the time delay and the degree of neurologic impairment before evacuation.

Background context Patients undergoing single-level posterior lumbar decompression and fusion (PLDF) usually do not need transfusions. However, patients undergoing two or three-level PLDF occasionally require transfusion postoperatively even when estimated blood loss (EBL) or blood loss from drains appears acceptable. Estimating the volume of HBL is critical in perioperative fluid management. Purpose To determine the volume of hidden blood loss (HBL) in 2- or 3- level PLDF. Study Design Single center, multi-surgeon, secondary analysis from a prospective randomized clinical trial of cell-saver use. Patient Sample Patients enrolled in a prospective randomized trial of cell-saver undergoing two- or three-level PLDF were included in this analysis. Methods Total blood loss was calculated using four estimation formulas including Bourke's, Gross’, Camarasa's, and Lopez-Picado's formulas. HBL was determined by subtracting the visible loss (EBL and blood loss from drains) from the calculated total blood loss. Results A total of 89 patients (36 males, mean age 62 years) were included. Seventy-five patients underwent open two-level fusion while 14 had three-level fusions. Intervertebral fusion was performed in 20 patients. Mean surgical time was 261 minutes, and EBL was 685 ml. Mean blood loss from drains was 824 ml. Seventy patients received allogenic blood while 47 Cell Saver blood reinfused intraoperatively. Hidden blood loss was calculated to be 678 ml, 963 ml, 1267 ml, and 819 ml using each formula. Conclusions HBL following two or three-level PLDF was substantial and more than EBL. Postoperative management of blood loss should take HBL into account.

BACKGROUND CONTEXT In patients with lumbar spinal stenosis, it is crucial for clinicians to identify all symptomatic levels. Prior studies have demonstrated that CT-myelography has a greater sensitivity in revealing stenosis (94.4%) compared to MRI (75.9%). CT-myelograms demonstrate weight-bearing changes as opposed to single position and single time point changes on MRI. However, CT-myelography is invasive, requiring injection of contrast dye into the thecal sac. PURPOSE The purpose of this study is to identify patients in whom additional levels of stenosis are likely to be recognized by a CT-myelogram following an MRI scan. STUDY DESIGN/SETTING Retrospective observational cohort at a single multi-surgeon spine center. PATIENT SAMPLE Patients ≥45 years old who had an MRI followed by a CT-myelogram within 6 months with a diagnosis of stenosis, spondylolisthesis, or degenerative scoliosis. OUTCOME MEASURES Additional levels of moderate to severe stenosis identified on CT-myelogram vs MRI. METHODS Medical records were reviewed to collect standard demographic and surgical data and to note if patients were deemed to have single-level or multi-level stenosis clinically. MRIs and CT-Myelograms obtained within six months of each other were reviewed and each lumbar level was recorded as mild, moderate, or severe based on the radiologist's report. Fisher's exact test was performed with change in recorded level of stenosis from MRI to CT-Myelogram as the primary outcome of interest. Results Of 207 patients, 139 (67%) had clinically reported multilevel stenosis and 68 (33%) had single-level stenosis. CT-Myelogram identified a greater proportion of additional stenotic levels in patients with clinically reported multilevel stenosis (80/139, 58%) compared to patients with single-level stenosis (27/68, 40%, p=0.018). When classifying patients based on MRI findings of stenosis instead of clinical diagnosis, 90 (43%) patients had multi-level stenosis, and 117 (56%) had single-level stenosis. In patients with radiologist-reported multilevel stenosis, CT-myelogram also identified a greater proportion of additional stenotic levels (55/90, 61%) compared to patients with radiologist-reported single level stenosis (52/117, 44%, p=0.025). Conclusions CT myelography is significantly more likely to provide valuable additional information in patients with multilevel stenosis as compared to patients with single level stenosis. This finding was consistent regardless of whether the distinction of single-level or multilevel stenosis was determined by clinical diagnosis or based solely off the MRI report. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Recent studies suggest as much as 25% of patients undergoing spine surgery are still on opioids two years later. In response, we developed protocols to minimize opioid consumption following elective spine surgery. Our goal was to evaluate patients undergoing single-level Anterior Lumbar Interbody Fusions (ALIF ± posterior fixation) on MMPC compared to patients who were not (nonMMPC). PURPOSE To determine if the combination of an oral preoperative pain cocktail with transverse abdominis plane (TAP) block (multi-modal pain control: MMPC) will reduce length of stay (LOS), ileus, and in-hospital opioid consumption. STUDY DESIGN/SETTING Retrospective chart review. PATIENT SAMPLE Consecutive patients undergoing single-level ALIF for degenerative lumbar conditions by a single-surgeon. OUTCOME MEASURES Length of stay (LOS), incidence of ileus and in-hospital opioid consumption. METHODS A retrospective review of a prospective, single-surgeon, surgical database was utilized for consistency in technique. Consecutive patients undergoing single-level ALIF for degenerative lumbar conditions were identified before and after initiation of the MMPC. The MMPC consisted of a preop oral regimen of cyclobenzaprine (10mg), gabapentin (600mg), acetaminophen (1g) and methadone (10mg). Postoperatively they received a bilateral transverse abdominis plane (TAP) block with 0.5% Ropivicaine. Our primary outcome was total, in-hospital opioid consumption (morphine milligram equivalents: MME). RESULTS There were 68 patients in the MMPC cohort and 39 in the nonMMPC cohort. There was no difference in baseline demographics such as sex, BMI, smoking, or preoperative opioid use between the two groups. The MMPC cohort was older (56.7 vs 51.1 years, p=0.026). Similar rates of ileus (4 vs 6, p=0.102), no difference in LOS (3.8 vs 4.5, p=0.246) and no difference in index hospital costs was found. Although there was no difference in day of surgery MMEs (58.5 vs 68.9, p=0.387), cumulative MMEs each day after surgery was significantly lower in the MMPC cohort, with final cumulative MMEs being reduced by 62% (120.2 vs 314.8, p CONCLUSIONS The use of a MMPC regimen in patients undergoing single-level ALIF for degenerative conditions reduced opioid consumption starting on POD 1, resulting in a cumulative reduction of 62%. Further research should strive to minimize opioid use and the downstream effects. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Posterior fixation with interbody cage placement can be accomplished via numerous techniques. In attempts to expedite recovery by limiting muscle dissection, the midline interbody fusion (MIDLIF) has been described. More recently, we have developed a robotic-assisted MIDLIF (RA-MIDLIF) technique. Introduction of new technology can potentially be expensive and burdensome. PURPOSE The purpose of this study was to compare index episode of care parameters between patients undergoing either traditional open TLIF (tTLIF), MIDLIF, or RA-MIDLIF. STUDY DESIGN/SETTING Retrospective review of a prospective, multisurgeon, surgical database. PATIENT SAMPLE Consecutive patients undergoing 1- or 2- level RA-MIDLIF, tTLIF or MIDLIF. OUTCOME MEASURES Estimated blood loss (EBL), operative tme (OR Time), length of stay (LOS), total direct hospital cost. METHODS A retrospective review of a prospective, multisurgeon, surgical database was utilized. Consecutive patients undergoing 1- or 2-level RA-MIDLIF for degenerative lumbar conditions were identified and propensity-matched based on age, sex, smoking status, BMI, ASA grade and levels fused to patients undergoing tTLIF or MIDLIF. LOS, EBL, OR Time and direct hospital cost for the index surgical admission were compared. RESULTS Of 55 RA-MIDLIF cases identified, 52 were successfully propensity-matched to patients undergoing tTLIF or MIDLIF. Consistent with propensity matching, there was no difference in age, sex, BMI, ASA grade, smoking status or levels fused. The mean direct hospital cost was similar across all cohorts. Patients undergoing RA-MIDLIF had a shorter average LOS (1.53 days) compared to either MIDLIF (2.71 days) or TLIF (3.58 days). Both MIDLIF and RA-MIDLIFs had lower EBL and less OR time compared to both tTLIF. CONCLUSIONS Despite concerns for additional cost and time while introducing navigation or robotic technology, a propensity-matched comparison of our first 52 robotic-assisted MIDLIF surgeries compared to tTLIF and MIDLIF showed promising results for reducing OR time, EBL, LOS and without increasing cost. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Surgeons have used lateral flexion–extension X-ray images to identify patients with clinically substantial instability and listhesis that require fusion. PURPOSE The purpose of this study is to determine the clinical utility of flexion–extension X-ray images by evaluating associations with supine MRI and lateral standing X-ray images and patient reported outcomes (PROs) at baseline and one-year post-op. STUDY DESIGN/SETTING Longitudinal cohort from a multisurgeon, single spine specialty practice. PATIENT SAMPLE Patients enrolled in quality outcome database from a single site with grade 1 spondylolisthesis. OUTCOME MEASURES Back pain (BP), leg pain (LP), and Oswestry Disability Index (ODI). METHODS Patients enrolled in QOD from a single site with grade 1 spondylolisthesis and complete preop and one-year postop PROs, including BP, LP, and ODI, and preop lumbar supine MRIs, lateral standing and flex–ext X-ray images were identified. Slip distance and percentage on all images were measured. Slip difference between flexion and extension was calculated. RESULTS Twenty-seven patients, mean age of 60.5years, 74% female were included. Mean listhesis on flexion films was significantly greater (8.5 mm) than on supine MRI (4.8 mm, p CONCLUSIONS There were no associations between preop or postop PROs and slip severity on any of the imaging modalities. As listhesis on standing and extension films were similar and slip difference between flexion and extension was not associated with PROs, lateral extension films may have limited clinical utility. Further studies are needed to clarify radiographic indications for fusion in patients with spondylolisthesis.

BACKGROUND CONTEXT Provisions in the Patient Protection and Affordable Care Act (PPAC) include alternative payment models that shift away from fee-for-service reimbursement and provide incentives to improve value. These reimbursement models could incorporate the post-discharge facility care and it is therefore important to identify drivers of additional cost, especially in the setting of unexpected non-home discharge. PURPOSE To identify factors associated with being discharged to a non-home location after an elective 1-2 level instrumented lumbar fusion that, if identified, can be useful to allow for early post-discharge planning. STUDY DESIGN/SETTING Retrospective chart review. PATIENT SAMPLE Patients undergoing 1-2 level instrumented lumbar fusions for degenerative lumbar conditions from 2016 to 2018. OUTCOME MEASURES Non-home discharge. METHODS Hospital administrative database and electronic medical record analysts identified consecutive patients undergoing 1-2 level instrumented lumbar fusions for degenerative lumbar conditions from 2016 to 2018. Discharge disposition was determined as home vs non-home (NH). A regression analysis was used to determine associations between NH discharge and an underserved zip code, ASA grade, marital status, race, insurance type, smoking status, BMI, number of levels, approach and revision surgery. RESULTS A total of 1,502 patients (601; 40% male) were included with a mean age of 57.5 years. The majority were discharged home (1,216; 81%). Of the 286 (19%) not discharged home, the majority went to a skilled nursing facility (248). Factors associated with a NH discharge were living in an underserved zip code, not being married, being on government insurance, having more levels fused, higher BMI and older age. Length of stay (5.64 vs 3.03 days, p CONCLUSIONS Patients living in an underserved zip code, not married, higher BMI, older, and having government insurance are more likely to be discharged to a non-home facility after undergoing 1-2 instrumented lumbar fusions. Identification and early intervention to place these patients even before admission may decrease the length of hospital stay and cost. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT In the future, payers may not cover unplanned 90-day emergency room (ER) visits or readmissions after elective lumbar spine surgery. Prior studies using large administrative databases lack granularity, and/or use a proxy for actual cost. We analyzed a large, single-center database to identify risk factors and subsequent costs associated with 90-day ER visits and readmissions. PURPOSE To identify risk factors and subsequent costs associated with 90-day ER visits and readmissions. STUDY DESIGN/SETTING Retrospective longitudinal cohort from a single multisurgeon, spine specialty site PATIENT SAMPLE Patients undergoing elective lumbar spine surgeries from 2013-2017. OUTCOME MEASURES Ninety-day ER visits and readmissions. METHODS A prospective, multisurgeon, single-center database merged with hospital administrative data was queried for elective lumbar spine surgeries from 2013-2017. Predictive models were created for 90-day ER visits and readmissions. RESULTS Of 5,444 patients, 729 (13%) returned to the ER, most often for pain (144, 32%). Predictors of an ER visit were prior ER visit (pER, OR:2.4), zip code (OR:1.4) and number of chronic medical conditions (OR:1.4). 421 (8%) patients were readmitted, most frequently for wound infection (123, 2%), COPD exacerbation (24, 0.4%), and sepsis (23, 0.4%). Predictors for readmission were pER (OR:1.96), multiple chronic conditions (OR:1.69), obesity (non-obese, OR:0.49), race (African American, OR:1.43), admission status (ER admission, OR:2.29) and elevated HbA1c (OR:1.80). Average direct hospital cost for an ER visit was $1,659 and readmission was $7,322, costing the institution $5.1 million over the five-year study period. CONCLUSIONS Risk factors for 90-day ER visit and readmission after elective lumbar spine surgery include medical comorbidities and socioeconomic factors. Proper patient selection, appropriate postop pain management and optimization of modifiable risk factors prior to surgery can lower the 90-day ER visits and readmissions and reduce health care costs. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Objective Posterior interbody fusion is commonly performed for degenerative lumbar conditions. A minimally invasive technique of midline exposure limited only to the facets and fixation with laterally directed cortical bone trajectory (CBT) screws was introduced with the intent of decreasing surgical morbidity. The purpose of this study was to determine if posterior interbody fusion with this limited midline exposure will have less blood loss and shorter operative times (i.e., can be considered minimally invasive) compared to traditional open transforaminal interbody fusion. Methods A consecutive single-surgeon series of patients who underwent posterior interbody fusion with either a navigated, midline only exposure (MidLIF) or full, traditional open, exposure of the transverse processes with a posterolateral fusion (open TLIF) were identified. Demographic, peri-operative data, patient reported outcomes (PROs), and reoperation/readmission rates were collected and compared. Results There were 29 cases in the MidLIF and 27 in the open TLIF group. Both groups were similar with respect to surgical indications, age, BMI, gender, ASA grade and operative level. The MidLIF group had significantly lower estimated blood loss (266 vs. 446 cc, p = 0.003), shorter operative time (170 vs. 210 minutes, p = 0.003), and shorter length of hospital stay (2.9 vs. 3.7 days, p = 0.016) compared to the open TLIF group. A sub-analysis of single-level cases showed similar findings with significantly lower estimated blood loss (247 vs. 411 cc, p = 0.10), shorter operative time (159 vs. 199 min, p = 0.003), and shorter length of hospital stay (2.9 vs. 3.7 days, p = 0.023) in the MidLIF group. Patient reported outcomes at 6 weeks, 3 months, 6 months, 12 months and 24 months post-operative favored MidLIF with significantly greater ODI improvements at both 6 weeks and 12 months; and lower ODI and back pain at both 12 months and 24 months. Conclusions MidLIF had lower blood loss and shorter operative time compared to the traditional open TLIF technique. These differences compare well to reported values in the literature for tubular minimally-invasive TLIF. Patient reported outcomes from 6 weeks to 24 months post-operative, hospital length of stay, and reoperation/readmission rates all favored MidLIF compared to traditional open TLIF.

BACKGROUND CONTEXT Our previous study showed that prescribing patterns, more than surgery invasiveness or patient factors, affect post-operative opioid consumption. Since then we have instituted a Standard Escalation Pain Protocol (SEPP): patients receive 0-60 Morphine Milligram Equivalents (MME) above their baseline pre-op MME after surgery. PURPOSE The purpose of this study is to evaluate how prescribing patterns affect immediate postoperative opioid consumption in patients undergoing 1- to 2-level posterior lumbar interbody fusion with a navigated or robotic-assisted, midline exposure (MIDLIF). STUDY DESIGN/SETTING Single surgeon consecutive series. PATIENT SAMPLE Patients with degenerative lumbar pathology who had a MIDLIF from 2017 to 2018 were identified. OUTCOME MEASURES In-hospital opioid consumption. METHODS Patients with degenerative lumbar pathology who had a MIDLIF from 2017 to 2018 were identified and divided into two cohorts: patients who had surgery before the institution of SEPP (PreSEPP) and those who had surgery after (PostSEPP). Length of stay and daily opioid consumption were extracted by EMR data analysts unaware of the purpose of the study. RESULTS The PreSEPP (N=34) and PostSEPP (N=27) patients were similar at baseline in age, sex distribution, ASA grade, BMI and smoking status. Pre-Op (2.2 vs 3.6, p=0.630) and Post-op Day-0 (POD-0, 52.5 vs 38.8, p=0.192) MME consumption was similar between the two groups. At POD-1, cumulative MME consumption was higher in the Pre-SEPP (131.7) compared to the PostSEPP group (76.0, p=0.004) and this was maintained up to discharge (54% total MME reduction). Length of stay was also longer in the PreSEPP (1.97 days) compared to the PostSEPP group (1.37 days, p=0.004). CONCLUSIONS The use of a standard escalation pain protocol decreases in-hospital opioid consumption by 54% and shortens length of stay after 1-2 level lumbar spinal fusion. Similar to our previous study, prescribing pattern is an important factor affecting post-op opioid consumption. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Background context Acinic cell carcinoma is the fourth most common tumor of the parotid gland, and spinal metastases are thought to be exceedingly rare. Only two other reported presentations are found in the literature, both presumably secondary to incomplete surgical resections. Purpose To present the first known case of metastasis to the lumbar spine causing vertebral body involvement, after complete resection of the parotid gland. Study design Case report. Methods A case of a patient who presented with low back pain and had imaging studies showing an expansive destructive lesion of the L4 vertebral body. The patient underwent a radical parotidectomy and radiation therapy for dedifferentiated, high-grade acinic cell carcinoma 2 years prior. Results The patient underwent anterior L4 corpectomy and strut cage placement and posterior pedicle screw fixation from L2 to L5 on the same day, followed by radiation and oral chemotherapy 3 weeks later. Histopathologic examination confirmed metastatic dedifferentiated acinic cell carcinoma, present in the L4 vertebral body and overlying psoas muscle. Conclusions This case report underscores the importance of careful evaluation of patients presenting with back pain with a history of malignancy. It also calls into question the traditional low-grade classification ascribed to these tumors, given their ability to metastasize after complete excision and adjuvant therapy.

BACKGROUND CONTEXT In 2016 alone, 19,413 deaths were attributed to prescription opioid overdoses. Understanding the drivers of opiate consumption in postoperative lumbar spinal fusion patients is a high priority. PURPOSE To determine if surgical invasiveness and/or preoperative opiate use influences immediate postoperative opiate consumption. STUDY DESIGN/SETTING Propensity matched longitudinal cohort. PATIENT SAMPLE Patients from a multi-surgeon, single spine specialty center with degenerative lumbar pathology who underwent an instrumented posterior lumbar decompression and interbody fusion (MIDLIF or TLIF). OUTCOME MEASURES Oswestry Disability Index, morphine equivalent doses (MED) from postoperative day (POD) #0 through POD #4. METHODS A single-center, multi-surgeon, retrospective review identified patients with degenerative lumbar pathology who underwent an instrumented posterior lumbar decompression and interbody fusion (MIDLIF or TLIF). Patients in each cohort were propensity-matched based on age, sex, smoking status, BMI, diagnosis, ASA grade and levels fused. MED POD #0 through POD #4 were calculated. Preoperative opiate prescriptions were recorded to determine baseline opioid use. RESULTS Of 214 MIDLIF and 281 TLIF patients undergoing surgery, 33 patients in each cohort were successfully propensity matched with no differences in baseline characteristics. There was no difference in immediate postoperative mean total MED between the cohorts (MIDLIF=370, TLIF=302, p=.398). Forty-three (65%) of patients were taking opiates prior to surgery. Opiate-naive patients required less narcotics (MED=248) compared to nonopiate naive patients (MED=383, p=.071) but this was not significant. Patients taking opiates preop had worse baseline ODI (56.5 vs. 47.2, p=.023) and 1-year postop ODI (46.3 vs. 30.9, p=.015). CONCLUSIONS Neither surgical invasiveness nor preoperative opiate use have an impact on immediate postop opiate consumption. This is likely secondary to non-individualized prescribing patterns. Patients taking preop narcotics have worse baseline, 1-year, and improvement in ODI following 1- and 2-level MIDLIFs or TLIFs. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Posterior instrumented lumbar fusions are commonly performed utilizing interbody fusions. Recently, a minimally invasive technique of midline exposure with cortical bone trajectory screw fixation has been described (MIDLIF). The goal is to limit muscle dissection, decreasing surgical morbidity and expedite recovery. PURPOSE The purpose of this study was to compare index episode of care (iEOC) cost between patients undergoing MIDLIF versus tTLIF. STUDY DESIGN/SETTING Multi-surgeon single-center spine specialty tertiary practice. PATIENT SAMPLE Consecutive patients undergoing 1- or 2-level MIDLIF or tTLIF for degenerative lumbar conditions were identified. OUTCOME MEASURES Index episode of care cost data for surgical and hospital stay parameters and included actual, direct, hospital cost. METHODS A retrospective review of a prospective, multi-surgeon, surgical database was utilized. Consecutive patients undergoing 1- or 2-level MIDLIF or tTLIF for degenerative lumbar conditions were identified. Patients in each cohort were propensity-matched based on age, sex, smoking status, BMI, diagnosis, ASA grade and levels fused. iEOC cost data was collected for surgical and hospital stay parameters and included actual, direct, hospital cost for the index surgical visit. RESULTS Of 214 and 281 patients undergoing MIDLIF or tTLIF, respectively, 105 cases in each cohort were successfully propensity-matched. Consistent with propensity matching, there was no difference in age, sex, BMI, diagnosis, ASA score, smoking status, or levels fused. Spondylolisthesis was the most common indication for surgery in both cohorts. The mean total iEOC was $706 ($16,604 vs. $17,310) lower for MIDLIF versus tTLIF. There was no difference in implant (p=.193) or biologic (p=.145) cost but blood utilization (p=.000), OR supplies (p=.000), hospital room/board (p=.000), pharmacy (p=.010), and therapy (p=.009) costs were all significantly lower in MIDLIF. Additionally, mean LOS was decreased for MIDLIF (2.97 vs. 4.02, p=.000). CONCLUSIONS Compared to traditional open tTLIF, patients undergoing MIDLIF have several cost parameters of the iEOC that are significantly lower as well as a shorter length of stay. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Background One of the primary difficulties in evaluating the effectiveness of lumbar fusion is that, with the exception of spondylolisthesis, specific diagnostic indications for surgery are poorly defined. Diagnostic specificity beyond the symptom of low back pain or the presence of lumbar degeneration needs to be delineated such that outcomes data can be effectively translated into clinical decision making or evidence-based guidelines. Purpose The purpose of this study was to report on prospectively collected clinical outcome measures, stratified by diagnosis, among a series of patients with lumbar degenerative disease whose treatment included lumbar spine fusion. Study design Demographics, diagnostic categorization, and clinical outcome measures were prospectively collected by six spine surgeons at a single tertiary spine center, as part of the surgeons' standard clinical practice. Patient sample Four hundred and twenty-eight patients were enrolled in the study and complete 1- and 2-year Health-Related Quality of Life (HRQOL) data were available in 327 patients whose treatment included decompression and posterolateral lumbar fusion. Outcome measures The Oswestry Disability Index (ODI), Short Form-36 (SF-36), numeric rating scales for back pain and leg pain. Methods Preoperative diagnosis was classified, in the primary surgical cases, as disc pathology, spondylolisthesis, instability, stenosis, or scoliosis. In revision cases, the diagnosis was classified as nonunion, adjacent level degeneration, or postdiscectomy revision. Patient-reported outcomes at 1 and 2 years post-op were assessed based on diagnostic stratification. Statistical evaluation of clinical outcome was performed for both mean net change in outcome scores and the percentage of patients reaching a minimum clinically important difference (MCID) threshold for each outcome measure. Results Preoperative diagnosis was spondylolisthesis (n=80), scoliosis (n=17), disc pathology (n=33), instability (n=21), stenosis (n=46), postdiscectomy revision (n=67), adjacent level degeneration (n=40), or nonunion (n=23). Evaluation of 2-year post-op HRQOL measures by diagnostic subgroup revealed the most substantial improvement in ODI score for patients with spondylolisthesis (22.7 points) and scoliosis (21.2 points). Patients with the diagnosis of disc pathology (16.2 points), postdiscectomy revision (14.0 points), instability (12.7 points), stenosis (10.6 points), and adjacent level degeneration (9.5 points) demonstrated a progressively smaller magnitude of ODI improvement. The least ODI improvement at 2 years after surgery was seen in patients with nonunion of a prior fusion (5.5 points). The percentage of patients reaching MCID for ODI at 2 years post-op ranged from 71.0% in the spondylolisthesis subgroup to 34.8% in the nonunion subgroup. The greatest SF-36 physical component score improvement at 2-year follow-up was seen in patients with disc pathology (7.9 points) and spondylolisthesis (7.7 points), followed by scoliosis (6.6 points) and stenosis (6.5 points), instability (5.6 points), postdiscectomy revision (5.3 points) nonunion (3.1 points) and adjacent level degeneration (2.5 points). No significant changes from Year 1 to Year 2 were noted in any of the subgroups. For SF-36 physical component score, percentage of patients reaching MCID ranged from 63.6% in the disc pathology subgroup to 25% in the nonunion subgroup. Conclusions This study supports the concept that added diagnostic specificity is a critical component in building an improved evidence base for lumbar fusion surgery. The magnitude of HRQOL improvement was not equal among diagnostic subgroups. The percentage of patients reaching an MCID level of improvement was also significantly influenced by diagnostic stratification. Without diagnostic specificity for entities beyond spondylolisthesis, the absence of well-defined study populations will continue to limit our ability to move toward evidence-based decision making.

Background context There is mounting evidence supporting the efficacy of bone morphogenetic protein (BMP) for both anterior interbody and posterolateral lumbar fusion. However, the relative cost of BMP remains an important concern for physicians, hospitals, and payers. Purpose The purpose of this study is to report on the perioperative costs for patients treated with rhBMP-2 as compared with an iliac crest bone graft (ICBG) supplemented with graft extenders. Study design/setting A prospective randomized controlled trial of rhBMP-2/ACS (Infuse Bone Graft; Medtronic Sofamor Danek, Memphis, TN) versus ICBG±graft extender for lumbar spine fusion in patients over 60 years old. Patient sample One hundred two patients over 60 years old who required a posterolateral lumbar spine fusion randomized between receiving rhBMP-2/ACS or ICBG. Outcome measures All health-care costs over the first 3 months after surgery. Methods As part of a prospective randomized trial of rhBMP-2/ACS versus ICBG±graft extender for lumbar spine fusion, all costs over the first 3 months after surgery were directly recorded by a dedicated coder funded by Norton Healthcare, Louisville, KY. A dedicated research nurse also followed all patients throughout their hospital stay and posthospitalization recovery to identify any adverse events or additional outpatient medical care. Results Fifty patients received rhBMP-2/ACS and 52 underwent ICBG harvest. The mean hospital cost for the index admission was $24,736 for the rhBMP-2/ACS group and $21,138 for the ICBG group. Mean inpatient physician costs were $5,082 in the rhBMP-2/ACS group and $5,316 in the ICBG group. Costs associated with posthospital rehabilitation averaged $4,906 in the rhBMP-2/ACS group versus $6,820 in the ICBG group. Total payer expenditure for the 3-month perioperative period averaged $33,860 in the rhBMP-2/ACS group and $37,227 in the ICBG group. Conclusions The hospital carries the cost burden associated with the utilization of rhBMP-2/ACS. In contrast, the payer in a Diagnosis-Related Group (DRG) model achieves a net savings, based primarily on the decreased payment for inpatient rehabilitation, but also on decreased hospital reimbursement, physician costs, and other outpatient services.

Posterior spinal arthrodesis is commonly employed in patients with spinal stenosis, although certain patients may require additional interbody support applied either anteriorly or posteriorly. Although autograft, allograft, and recent biologic agents such as rhBMP-2 are available for arthrodesis, meticulous fusion technique is still essential for a successful result. Posterior pedicular screw and rod fixation remain the most commonly employed internal fixation for the treatment of spinal stenosis since it allows for stabilization of instability, correction of deformity, and improved arthrodesis success. This article outlines the etiology, pathogenesis, current treatment options, and various surgical techniques available for the treatment of spinal stenosis.

Spondylolisthesis is defined as the forward translation of one vertebra on another in the sagittal plane. There are multiple etiologies of spondylolisthesis, including the degenerative and postsurgical varieties. Degenerative spondylolisthesis presents in a more elderly population and usually involves the lumbar fourth and fifth vertebrae. The pathogenesis is believed to be secondary to the progressive degeneration of the disc and facets, which results in instability and pathologic segmental motion. Clinically, patients present with low back pain and neurological symptoms consisting of spinal claudication or radiculopathy. A postsurgical spondylolisthesis is often the inevitable result of decompression with up to 50% of patients developing late instability that requires stabilization. Similar to a degenerative spondylolisthesis, these patients will present with reoccurrence of radicular pain associated with increasing low back pain. A spondylolisthesis is identified with plain radiographs, which should include flexion and extension to identify pathologic motion. An MRI is useful for the evaluation of stenosis, while a Myelo/CT with flexion and extension weight-bearing views is superior for the evaluation of dynamic instability. Nonoperative treatment consists of bracing, nonsteroidal antiinflammatory medication, epidural blocks, weight reduction, and physical therapy. Surgical indications include severe back pain or neurological symptoms. Following decompression, an arthrodesis is recommended for a degenerative spondylolisthesis since long-term studies have demonstrated improved outcomes. A postsurgical spondylolisthesis, by definition, is unstable and requires a concurrent stabilization. Surgical options include posterior pedicular rod and screw fixation, posteriorly placed interbody implants combined with pedicular instrumentation, or combined anterior and posterior procedures. Materials available for fusion include autograft, allograft, or new biologic graft substitutes such as rhBMP-2. This article reviews the etiology and pathogenesis of spondylolisthesis along with recommended treatment options and surgical techniques to enable clinicians to insure superior patient treatment outcomes.

Thirty patients (31 shoulders) were retrospectively reviewed after hemiarthroplasty for glenohumeral osteoarthritis. Ten shoulders had primary osteoarthritis, and 21 shoulders had secondary osteoarthritis. Glenoid surface wear was evaluated and classified as either type I, concentric, (15 shoulders) or type II, nonconcentric, (16 shoulders). Postoperative results were reviewed with the American Shoulder and Elbow Surgeons' evaluation form, Neer classification, and the Constant score. Overall, 23 (74%) shoulders achieved satisfactory results, and 8 (26%) shoulders had unsatisfactory results. Results were similar in the primary and secondary osteoarthritis groups. Outcome correlated most significantly with the status of posterior glenoid wear. Patients with concentric, type I glenoids achieved 86% satisfactory results, whereas patients with nonconcentric, type II glenoids had only 63% satisfactory results. Although pain relief was similar in both groups, the unsatisfactory results were attributed to loss of forward elevation and external rotation in patients with type II glenoids. On the basis of these results hemiarthroplasty can be an effective treatment for both primary and secondary arthritis but should be reserved for patients with a concentric glenoid, which affords a better fulcrum for glenohumeral motion. (J Shoulder Elbow Surg 1997;6:449-54.)

Tendons are complex composite material composed primarily of water, collagen, proteolycans, and cells, designed to transmit tensile loads from muscle to bone. Although rotator cuff tendons differ in many ways from other tendons in the body, a knowledge of basic tendon structure and function is helpful in understanding rotator cuff tendon biology, injury, and repair. In addition to type I collagen, rotator cuff tendons contain small amounts of type III collagen, which play a role in healing and repair. In comparison with other tendons, the increased glycosaminoglycan and proteoglycan content seen in rotator cuff tendons may be adaptive, pathologic, or both. The etiology of rotator cuff pathology is probably related to trauma, aging, and degeneration. As our understanding of these processes increases, we will be able to develop and implement improved preventative and therapeutic interventions for rotator cuff pathology.

greater improvement in VAS pain for ProDisc-NR (89.6%) than for ProDisc-L-R (79.2%). There was no difference between F/E ROM measurements between ProDisc-L-NR (8.864.59 ) and ProDisc-L-R (7.764.67 ). There were no reoperations in the ’training cases’ versus (6/161) in the randomized patients. CONCLUSIONS: This study reports Class I data for the ProDisc-L. There was no difference in operative time, blood loss, and hospital stay between ‘training cases’ and randomized patients treated with ProDisc-L. Outcomes of ‘training cases’ were similar or improved compared with patients treated with ProDisc-L in the randomized study. These results support the ease and reproducibility of the ProDisc-L technique and instrumentation and a rapid learning curve for the surgical procedure. FDA DEVICE/DRUG STATUS: ProDisc-L: Approved for this indication. CONFLICT OF INTEREST: Author (JZ) Consultant: Synthes Spine; Author (JZ) Grant/Research Support: Synthes Spine.