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BACKGROUND CONTEXT Lumbar degenerative stenosis is one of the most common spine pathologies for which surgical intervention is indicated. There is some evidence that a prolonged duration of neurological compression could lead to a failure of surgery to alleviate symptoms. PURPOSE Determination of whether longer symptom duration was associated with worse postoperative disability outcomes after decompressive surgery for lumbar degenerative stenosis. STUDY DESIGN/SETTING The Canadian Spine Outcomes and Research Network (CSORN) prospective database includes pre- and postoperative data from 18 tertiary care hospitals. PATIENT SAMPLE The CSORN database was queried for all cases of degenerative lumbar stenosis receiving surgical decompression for neurogenic claudication or radiculopathy. Patients with tumor, infection, fracture, or previous surgery were excluded. Patients were divided into groups based on symptom duration ( 2 years). OUTCOME MEASURES Change between preoperative and 12-month postoperative Oswestry Disability Index (ODI) was compared between symptom duration groups. Secondary outcomes included SF12 physical component score (PCS), and numeric rating scales for leg and back pain. Outcomes were also assessed at 3 months and 24 months postoperatively. METHODS Change in ODI, and secondary outcome measures, were compared between different symptom duration groups. Multiple regression analysis was used to identify factors interacting with symptom duration to predict change in ODI. RESULTS Four hundred and seventy-eight cases of lumbar stenosis with 12-month postoperative data were identified. Longer symptom duration correlated with less improvement in ODI (p 1 year of symptoms were less likely to achieve a Minimal Clinically Significant Difference in ODI (54.4% vs. 66.1%; p=.03) and were more likely to experience no improvement or worse disability, postoperatively (22.1% vs. 11.3%; p=.008). Similar results were found at 3- and 24-month timepoints. Smaller postoperative improvements in SF12 PCS and leg pain scales were also correlated with longer symptom duration (p CONCLUSIONS Multicenter registry data provides important real-world evidence to guide consent, surgical planning, and health resource management. Longer symptom duration was found to correlate with less improvement in pain and disability after lumbar stenosis surgery suggesting that these patients may benefit from earlier treatment.

Surgeons may not have a thorough knowledge about the costs of devices or surgical equipment. The main reason for this in many systems is price insensitivity. The purpose of this study was to determine whether spine surgical procedural expenses change once physicians are aware of the costs for surgical implants and the total associated costs with the procedure. A thorough bottom up case costing methodology was used to capture the costs of admission for three comparable spine surgical procedures at a large tertiary care center. Costs were collected for an initial 5-month period where surgeons were not aware of costs, followed by another 5-month period with detailed cost information. Instrumental costs, procedural costs and costs of admission were captured as well as health related quality of life (HRQOL) measures at 3 months. Statistical analysis was undertaken with STATA software. Costs decreased by $478 for instrumentation once actual prices were known (p = 0.069). Only ACDF procedures demonstrated statistically significant instrumental cost savings of $754 (p = 0.009). Total procedural costs were also less ($297, p = 0.194) but the total overall costs of admission increased ($401, p = 0.228). There were no differences in VAS, EQ-5D, or SF-12 scores. Although costs decrease for implants in surgery when prices are known, this appears to have little or no effect on overall costs of care. Length of stay and operating room time have greater effects on global costs. Future efforts to encourage efficient cost savings should focus on practice patterns/pathways for similar conditions rather than limiting the use of certain implants.

It is controversial whether the surgical restoration of sagittal balance and spinopelvic angulation in a single level lumbar degenerative spondylolisthesis results in clinical improvements. The purpose of this study to systematically review the available literature to determine whether the surgical correction of malalignment in lumbar degenerative spondylolisthesis correlates with improvements in patient-reported clinical outcomes. Literature searches were performed via Ovid Medline, Embase, CENTRAL and Web of Science using search terms "lumbar," "degenerative/spondylolisthesis" and "surgery/surgical/surgeries/fusion". This resulted in 844 articles and after reviewing the abstracts and full-texts, 13 articles were included for summary and final analysis. There were two Level II articles, four Level III articles and five Level IV articles. Most commonly used patient-reported outcome measures (PROMs) were Oswestery disability index (ODI) and visual analogue scale (VAS). Four articles were included for the final statistical analysis. There was no statistically significant difference between the patient groups who achieved successful surgical correction of malalignment and those who did not for either ODI (mean difference -0.94, CI -8.89-7.00) or VAS (mean difference 1.57, CI -3.16-6.30). Two studies assessed the efficacy of manual reduction of lumbar degenerative spondylolisthesis and their clinical outcomes after the operation, and there was no statistically significant improvement. Overall, the restoration of focal lumbar lordosis and restoration of sagittal balance for single-level lumbar degenerative spondylolisthesis does not seem to yield clinical improvements but well-powered studies on this specific topic is lacking in the current literature. Future well-powered studies are needed for a more definitive conclusion.

BACKGROUND CONTEXT Spine surgeries utilize significant hospital resources, with length of stay (LOS) being a major cost driver. Predicting inpatient hospitalization is essential for the operational success of a hospital. Previous studies identifying pertinent factors that impact LOS in spine surgery are limited. PURPOSE To identify pre-, intra-, and post-operative factors associated with LOS in patients undergoing spine surgery. STUDY DESIGN/SETTING Retrospective review of spine surgery patients at a Canadian tertiary academic teaching hospital. PATIENT SAMPLE A total of 415 spine surgery patients. OUTCOME MEASURES LOS (calculated from the date of surgery to the date of discharge, with no accommodation for partial days). METHODS Institutional research ethics board (IRB) approval was obtained. Patients undergoing surgery by two orthopedic spine surgeons between October 2014 to October 2016 were identified using billing codes. Chart data were extracted on 16 surgical and nonsurgical factors by two independent reviewers. Factors collected included age, sex, BMI, ASA class, insurance claim, transfusion, preop medication use (antidepressant, neuroleptic and narcotic), surgical procedure (sub-grouped into 10 categories: single level transforaminal lumbar interbody fusion (TLIF), 2-level TLIF, discectomy, laminectomy, posterior c-spine, minimally-invasive stabilization, anterior lumbar interbody fusion (ALIF), anterior cervical decompression and fusion (ACDF), major deformity, and other (hematoma, removal of hardware, incision and drainage), Charlson Comorbidity Index, preop hemoglobin, surgical time, initial versus revision surgery, intraop analgesic dose, and LOS. Multiple quasi-poisson regression was used to identify factors associated with LOS. RESULTS There were 378 patients with full data included in the final analysis. Average age of the cohort was 52 years (16.3 sd, range 16-88) and 51% were female. Thirty percent (n=123) of the procedures were 1-level TLIF, while 6% (n=25) were 2-level TLIF. Other prominent procedures included discectomy (18%), laminectomy (15%) and posterior c-spine (7%). The average LOS for the entire cohort was 5.9 ±11.0 days and was right skewed: 58 subjects (14%) had 0 days in hospital and 59 subjects (14%) stayed longer than 1 week. A poisson model was built to predict LOS with surgical procedure while controlling for the other study variables. Compared to patients undergoing one- or two-level laminectomy, those that had single level or two-level discectomy stayed less than half as long (IRR=0.44, 95% CI: [0.24, 0.80]). Posterior c-spine patients (IRR=4.92, 95% CI: [2.92, 8.28]), major deformities (IRR=3.07, 95% CI: [1.85, 5.10]), ACDFs (IRR=2.24, 95% CI: [1.21, 4.15]), and 1-level TLIFs (IRR=1.50, 95%CI: [1.03, 2.16]) all had significantly longer hospital stays. Amongst the other study variables, ASA class 4 patients had a significantly longer stay (IRR=4.3), and patients that received a transfusion also stayed longer (IRR=2.7). All other factors evaluated were not found to be independently predictive of LOS. CONCLUSIONS The LOS within this cohort is strongly correlated with the procedure performed. Medical comorbidities and other factors did not significantly impact LOS except in very ill patients. Future pathway improvement should focus on procedure-specific, post-operative rehabilitation protocols and appropriate pre-operative optimization of severe medical illness. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Surgery for degenerative lumbar spondylolisthesis (DLS) has traditionally been indicated for patients with neurogenic claudication and radicular pain. Surgery improves patients’ disability and lower extremity symptoms, but little is known about the impact on back pain. PURPOSE This study aims to evaluate changes in back pain after surgery and identify prognostic factors influencing these changes in surgically treated DLS. METHODS Consecutive patients with DLS surgically treated were prospectively enrolled in the Canadian Spine Outcomes Research Network (CSORN) registry. Patients had demographic data, clinical information, disability (ODI), and back pain (NRS Back Pain) scores collected prospectively at baseline, 3-, 12-, and 24-month follow-up. Results were compared to baseline using simple summary statistics and factors associated with improved back pain were assessed with multivariate regression (significance was p RESULTS A total of 557 patients were identified; all had reached 3-month follow-up; 376 (67.5%) had reached 12-month follow-up; and 141 (25.3%) had reached 24-month follow-up. Mean age at baseline was 66.2 (+/−9.5), and 58.5% were female. Back pain improved significantly at 3 months, and was maintained at 12, and 24-month follow-up compared to baseline (p CONCLUSIONS Back pain improved significantly during follow up for patients treated surgically for DLS. This research demonstrates that for patients undergoing surgery for DLS, the majority will have improved back pain at 1-year follow-up. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT The importance of sagittal balance and spinopelvic parameters are recognized in the management and outcomes of adult spinal deformity and isthmic spondylolisthesis, but less is known regarding their role in degenerative lumbar spondylolisthesis (DLS). The purpose of this study is to determine the influence of baseline sagittal balance and spinopelvic parameters on pain, function, and health-related quality of life (HRQOL) of patients presenting with DLS. PURPOSE The purpose of this study is to determine the influence of baseline sagittal balance and spinopelvic parameters on pain, function, and health-related quality of life (HRQOL) of patients presenting with DLS. STUDY DESIGN/SETTING Prospective, multi-center study from the Canadian Spine Outcome and Research Network (CSORN). PATIENT SAMPLE Patients with DLS were enrolled in a prospective, multi-center study between 2015 and 2017. Inclusion into this study required DLS at 1 or 2 levels and symptoms of neurogenic claudication or radicular pain with our without back pain. Patients were excluded if they had previous lumbar spine surgery or the presence of another condition which significantly affected function OUTCOME MEASURES Patient-rated outcome measures included the Numeric Pain Rating Scale (NPRS) for back pain and leg pain, Oswestry Disability Index (ODI), SF-12 Physical Component Summary score (PCS) and Mental Component Summary score (MCS), EQ-5D. Pelvic parameter measurements included: sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), sagittal vertical axis (SVA), lumbar lurdosis (LL), thoracic kyphosis (TK), T1 spino-pelvic inclination (T1 SPI), and T9 spino-pelvic inclination (T9 SPI). METHODS Baseline patient demographics, radiographic spinopelvic parameters, and sagittal alignment were analyzed for possible correlation to HRQOL using Pearson correlations. RESULTS A total of 154 patients were analyzed (mean age: 65.8, BMI: 29.1) with grade I (72%) or II (28%) DLS, of which 95 were females. Primary symptoms were related to neurogenic claudication (80%), radiculopathy (15.3%) or back pain (4.7%). On average, symptom duration was greater than 2 years in 71% of patients. Patients had moderate to severe symptoms and disability (mean NRS back: 7.2, NRS leg: 7.3, ODI: 45.6, PCS-12: 33.2, MCS-12: 49.6, EQ-5D: 0.54). Baseline measurements of radiographic alignment included sacral slope (SS=34.9±16.7°), pelvic tilt (PT=24.8±9.5°), pelvic incidence (PI=57.4±13.8°), sagittal vertical axis (SVA=35.8±40.8mm), lumbar lordosis (LL=45.7±13.6°), thoracic kyphosis (TK=36.8±13.0°), T9-spinopelvic inclination (T9SPI=9.62±4.0°), and T1-spinopelvic inclination (T1SPI=4.43±10.4°). There were 54% of patients who had an insufficient lumbar lordosis based on the relationship between PI and LL (LL CONCLUSIONS Patients with DLS have global sagittal misalignment compared to published normative controls, highlighted by less lumbar lordosis, a PI to LL mismatch, and increased PT. Spinopelvic alignment was not associated with patient outcomes, although positive sagittal balance may also be influenced by spinal stenosis. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.