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BACKGROUND CONTEXT Excessive use of postoperative imaging after lumbar surgery has been documented, becoming a target for cutting costs. This must be balanced with the patient's need for information and allay their postoperative concerns. PURPOSE To determine the incidence and associated costs of patient interactions with the healthcare system, outside the standard follow up routine, in the first postoperative year. STUDY DESIGN Retrospective longitudinal cohort. PATIENT SAMPLE Consecutive series of 200 patients who underwent lumbar fusions from 2018 to 2019 from a multi-surgeon single tertiary spine center. OUTCOME MEASURES All healthcare encounters: phone calls, office and emergency department visits, and additional testing METHODS A consecutive series of 200 patients who underwent lumbar fusions from 2018 to 2019 were identified. All non-routine healthcare encounters: phone calls, office and emergency department visits, and additional testing were collected. Direct costs for all healthcare services were determined using the Medicare Allowable rates. Indirect costs were determined using local, median income, length of office visits, and distance from the clinic to the patient's home. RESULTS Of 200 patients, 14 with thoracic fusion were excluded. The mean age of the 186 included patients was 58.26 years and 85 (46%) were male. Forty-seven percent (87/186) had only routine postoperative visits and 24 had revision surgery. Seventy-five patients made a total of 102 phone calls, 55 office visits, leading to 38 diagnostic studies none of which led to an additional intervention. Using Medicare Allowable rates, the mean direct cost was $776 per patient and the using a median income of $16/h the mean indirect cost was $124 per patient. There were no differences in the baseline characteristics among the patients who only had routine post-op encounters, had non-routine encounters or had a repeat surgery. CONCLUSIONS Forty percent of the patients undergoing lumbar surgery had a healthcare encounter outside their routine follow up that did not result in additional intervention after their index operation. These potentially unnecessary encounters create additional cost and inconvenience to both the patient and healthcare system. Providing patient reassurance is important and providers should identify ways to reduce associated costs through patient education, virtual visits, or new technologies to monitor patient's postoperative progress.

Patients with advanced pyogenic spondylodiscitis can present with neurologic deficits. However, the prevalence, severity, and outcome of the neurologic deficits are not well known. A systematic review was performed to improve the knowledge of this commonly encountered clinical scenario. The considerable number of severe neurologic deficits in addition to their poor recovery, even after surgical intervention, demonstrates that the early diagnosis of pyogenic spondylodiscitis is crucial. Prompt surgical intervention is likely associated with a greater chance of improvement of neurologic status than nonsurgical treatment.

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.

STUDY DESIGN Retrospective single center propensity-matched observational cohort study that included patients who underwent 1- to 3-level lumbar fusion surgery for degenerative conditions. OBJECTIVE To compare 90-day complication rates between robotic-assisted and non-robotic-assisted lumbar spinal fusions in propensity-matched cohorts. SUMMARY OF BACKGROUND DATA A recent administrative database (PearlDiver) study reported increased 30-day complications with the utilization of robotic-assisted enabling technology. METHODS Of 146 robotic-assisted cases that met inclusion criteria, 114 were successfully propensity matched to 114 patients from 214 cases who had 1 to 3 level lumbar fusion without robotic assistance based on age, sex, body mass index, smoking status, American Society of Anesthesiologist grade, number of surgical levels, primary versus revision, and surgical approach (posterior-only or anterior-posterior). We excluded tumor, trauma, infection, or deformity cases. Outcomes included surgical and medical (major/minor) complications at intraoperative, immediately postoperative, 30- and 90-day postoperative intervals, including reoperations, and readmissions within 90 days. RESULTS All cause intraoperative complication rates were similar between non-robotic-assisted (5.3%) and robotic-assisted groups (10.5%, P = 0.366). Immediate postoperative medical complication rate was also similar between non-robotic-assisted (6.1%) and robotic-assisted groups (1.8%, P = 0.089). Thirty-day complication rates, 90-day complication rates, reoperation rates, and readmission rates showed no difference between non-robotic-assisted and robotic-assisted groups. There was no difference between return to OR for infection between the cohorts (non-robotic-assisted: 6 [5%] vs. robotic-assisted: 1 [0.8%], P = 0.119). There was however improved length of stay (LOS) in the robotic-assisted group compared with non-robotic-assisted group (2.5 vs. 3.17 days, P = 0.018). CONCLUSION In propensity-matched cohorts, patients undergoing 1- to 3-level robotic-assisted posterior lumbar fusion for degenerative conditions did not have increased 90-day complication rate, and had a shorter length of stay compared with non-robotic-assisted patients. There findings differ from a prior administrative database study as the robotic-assisted group in the current study had 0% return to OR for malpositioned screws and 0.8% return to OR for infection.Level of Evidence: 2.

Background Lumbar disc herniation (LDH) is a common problem. When surgical treatment is required, the intervention is typically decompression without fusion. Successful return-to-work (RTW) is a standard expectation with these limited procedures. Occasionally, the size or location of the disc herniation suggests the need for fusion, but the inability to RTW is a significant concern in these cases. The purpose of this study is to determine if the addition of lumbar fusion, as compared to decompression alone, will substantially diminish RTW in patients with lumbar disc herniation. Methods This is a longitudinal cohort study using prospectively collected data from the Quality and Outcomes Database (QOD). Patients with LDH, eligible to RTW (not retired, a student, or on disability) with complete 12-month follow-up data, were identified. Standard demographic and surgical variables, patient-reported outcomes (PROs), and RTW status at 3 and 12 months were collected. Results Of the 5062 patients identified, 4560 (90%) had decompression alone and 502 (10%) had a concurrent fusion. Age and gender were similar in the two groups. The fusion group had worse back pain (NRS 6.52 vs. 5.96) and less leg pain (6.31 vs. 7.01) at baseline compared to the no fusion group. Statistically significant improvement in all PROs was seen in both groups. RTW at 3 months post-op was seen in 85% of decompression cases and 66% of cases with supplemental fusion. At 12 months post-op, RTW increased to 93% and 82%, respectively. Conclusion The need for fusion in LDH cases is unusual, seen in only 10% of cases in this series. The addition of fusion decreased the RTW rate from 85 to 66% at 3 months and from 93 to 82% at 12 months post-op. While the difference is significant, the ultimate deterioration in RTW may be less than anticipated. A reasonable RTW rate can still be expected in the rare patient who requires fusion as part of their treatment for LDH.

Retrospective chart review. To determine if the addition of an anterior lumbar interbody fusion (ALIF) improves the fractional curve in adult spinal deformity correction when compared to posterior surgery alone. ALIF is commonly advocated to improve lordosis and fusion in adult deformity surgery. Improved fractional curve correction may help level the pelvis and minimize proximal malalignment. Patients undergoing thoracolumbar fusion to the pelvis with S2AI screws for deformity were identified and stratified into patients who had an ALIF as part of their deformity correction procedure (ALIF + PSF), and those who had a posterior approach alone. The posterior approach (PSF) includes patients who had a posterolateral fusion with or without a transforaminal lumbar interbody fusion (TLIF). Radiographic parameters measured included pre-op and post-op fractional coronal curve Cobb angle, lumbar lordosis, pelvic tilt, pelvic incidence and sacral slope, major Cobb angle, coronal and sagittal SVA. There were 31 cases in the ALIF + PSF group and 28 in the PSF group. Baseline demographic characteristics of the two groups were similar. Mean pre-op fractional coronal Cobb (18.3° vs 13.4°, p = 0.027) was larger in the ALIF + PSF group, whereas lumbar lordosis (31.0° vs 33.6°, p = 0.487) and pelvic parameters were similar between the two groups. Post-op lumbar lordosis was similar (48.2° vs 43.0°, p = 0.092). Greater fractional coronal curve correction was achieved in the ALIF + PSF group (67%) compared to the PSF group (36%) with a smaller post-op fractional coronal curve in the ALIF + PSF group (6.1°) compared to the PSF group (8.6°, p = 0.053). There is a greater correction of the fractional curve in the ALIF + PSF group compared with the PSF group. While this may not be the primary indication for ALIF, it is a benefit which may facilitate overall deformity correction and leveling of the pelvis.

OBJECTIVELumbar fusion can lead to significant improvements in patient-reported outcomes (PROs) in patients with degenerative conditions. It is unknown whether the presence of hip or knee arthritis confounds the responses of patients to low-back–specific PROs. This study examined PROs with lumbar fusion in patients with concomitant lower-extremity arthritis. The purpose of the current study was to examine whether patients with significant lower-extremity arthritis who undergo lumbar fusion achieve similar improvements in low-back–specific PROs compared to patients without lower-extremity arthritis.METHODSPatients were identified from a prospectively enrolled multicenter registry of patients undergoing lumbar fusion surgery for degenerative conditions. Two hundred thirty patients identified with lumbar fusion and who also had concomitant lower-extremity arthritis were propensity matched to 233 patients who did not have lower-extremity arthritis based on age, BMI, sex, smoking status, American Society of Anesthesiologists grade, number of levels fused, and surgical approach. One-year improvement in PROs, numeric rating scales (0–10) for back and leg pain, and the Oswestry Disability Index and EuroQol-5D scores were compared for patients with and without lower-extremity arthritis.RESULTSBaseline demographics and preoperative outcome measures did not differ between the two propensity-matched groups with 110 cases each. Patients with concomitant lower-extremity arthritis achieved similar improvement in health-related quality-of-life measures to patients without lower-extremity arthritis, with no significant differences between the groups (p > 0.10).CONCLUSIONSThe presence of lower-extremity arthritis does not adversely affect the results of lumbar fusion in properly selected patients. Patients with lower-extremity arthritis who undergo lumbar fusion can achieve meaningful improvement in PROs similar to patients without arthritis.

OBJECTIVENational databases collect large amounts of clinical information, yet application of these data can be challenging. The authors present the NeuroPoint Alliance and Institute for Healthcare Improvement (NPA-IHI) program as a novel attempt to create a quality improvement (QI) tool informed through registry data to improve the quality of care delivered. Reducing the length of stay (LOS) and readmission after elective lumbar fusion was chosen as the pilot module.METHODSThe NPA-IHI program prospectively enrolled patients undergoing elective 1- to 3-level lumbar fusions across 8 institutions. A three-pronged approach was taken that included the following phases: 1) Research Phase, 2) Development Phase, and 3) Implementation Phase. Primary outcomes were LOS and readmission. From January to June 2017, a learning system was created utilizing monthly conference calls, weekly data submission, and continuous refinement of the proposed QI tool. Nonparametric tests were used to assess the impact of the QI intervention.RESULTSThe novel QI tool included the following three areas of intervention: 1) preoperative discharge assessment (location, date, and instructions), 2) inpatient changes (LOS rounding checklist, daily huddle, and pain assessments), and 3) postdischarge calls (pain, primary care follow-up, and satisfaction). A total of 209 patients were enrolled, and the most common procedure was a posterior laminectomy/fusion (60.2%). Seven patients (3.3%) were readmitted during the study period. Preoperative discharge planning was completed for 129 patients (61.7%). A shorter median LOS was seen in those with a known preoperative discharge date (67 vs 80 hours, p = 0.018) and clear discharge instructions (71 vs 81 hours, p = 0.030). Patients with a known preoperative discharge plan also reported significantly increased satisfaction (8.0 vs 7.0, p = 0.028), and patients with increased discharge readiness (scale 0–10) also reported higher satisfaction (r = 0.474, p < 0.001). Those receiving postdischarge calls (76%) had a significantly shorter LOS than those without postdischarge calls (75 vs 99 hours, p = 0.020), although no significant relationship was seen between postdischarge calls and readmission (p = 0.342).CONCLUSIONSThe NPA-IHI program showed that preoperative discharge planning and postdischarge calls have the potential to reduce LOS and improve satisfaction after elective lumbar fusion. It is our hope that neurosurgical providers can recognize how registries can be used to both develop and implement a QI tool and appreciate the importance of QI implementation as a separate process from data collection/analysis.

BACKGROUND: The opioid epidemic is at epic proportions currently in the United States. Exposure to opioids for surgery and subsequent postoperative pain management is a known risk factor for opioid dependence. In addition, opioids can have a negative impact on multiple aspects including clinical outcomes, length of hospital stay, and overall cost of care. Thus, the greatest effort to reduce perioperative opioid use is necessary and a multimodal pain control (MMPC) has been gaining popularity. However, its efficacy in spine surgery is not well known. We aimed to evaluate the efficacy of a MMPC protocol in patients undergoing lumbar single-level anterior lumbar interbody fusion (ALIF). METHODS: This is a retrospective comparative study. From a prospective, single-surgeon, surgical database, consecutive patients undergoing single-level ALIF with or without subsequent posterior fusion for degenerative lumbar conditions were identified before and after initiation of the MMPC protocol. The MMPC protocol consisted of a preoperative oral regimen of cyclobenzaprine (10 mg), gabapentin (600 mg), acetaminophen (1 g), and methadone (10 mg). Postoperatively they received a bilateral transverse abdominis plane block with 0.5% Ropivacaine prior to extubation. We compared in-hospital opioid consumption between the MMPC and non-MMPC cohorts as well as baseline demographic, the length of hospital stay, cost, and rate of postoperative ileus. Opioid consumption was calculated and normalized to the morphine milligram equivalents (MMEs). RESULTS: In total, 68 patients in the MMPC cohort and 39 in the non-MMPC cohort were identified. There was no difference in baseline demographics including sex, body mass index, smoking status, or preoperative opioid use between the two groups. Although there was no difference in the MMEs on the day of surgery (58.5 vs. 66.9, 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

OBJECTIVEUnexpected nonhome discharge causes additional costs in the current reimbursement models, especially to the payor. Nonhome discharge is also related to longer length of hospital stay and therefore higher healthcare costs to society. With increasing demand for spine surgery, it is important to minimize costs by streamlining discharges and reducing length of hospital stay. Identifying factors associated with nonhome discharge can be useful for early intervention for discharge planning. The authors aimed to identify the drivers of nonhome discharge in patients undergoing 1- or 2-level instrumented lumbar fusion.METHODSThe electronic medical records from a single-center hospital administrative database were analyzed for consecutive patients who underwent 1- to 2-level instrumented lumbar fusion for degenerative lumbar conditions during the period from 2016 to 2018. Discharge disposition was determined as home or nonhome. A logistic regression analysis was used to determine associations between nonhome discharge and age, sex, body mass index (BMI), race, American Society of Anesthesiologists grade, smoking status, marital status, insurance type, residence in an underserved zip code, and operative factors.RESULTSA total of 1502 patients were included. The majority (81%) were discharged home. Factors associated with a nonhome discharge were older age, higher BMI, living in an underserved zip code, not being married, being on government insurance, and having more levels fused. Patients discharged to a nonhome facility had longer lengths of hospital stay (5.6 vs 3.0 days, p < 0.001) and significantly increased hospital costs ($21,204 vs $17,518, p < 0.001).CONCLUSIONSIncreased age, greater BMI, residence in an underserved zip code, not being married, and government insurance are drivers for discharge to a nonhome facility after a 1- to 2-level instrumented lumbar fusion. Early identification and intervention for these patients, even before admission, may decrease the length of hospital stay and medical costs.

OBJECTIVELoss to follow-up has been shown to bias outcomes assessment among studies utilizing clinical registries. Here, the authors analyzed patients enrolled in a national surgical registry and compared the baseline characteristics of patients captured with those lost to follow-up at 2 years.METHODSThe authors queried the Quality Outcomes Database for patients with grade I lumbar degenerative spondylolisthesis undergoing a surgical intervention between July 2014 and June 2016. Only those patients enrolled in a multisite study investigating the impact of fusion on clinical and patient-reported outcomes (PROs) among patients with grade I spondylolisthesis were evaluated.RESULTSOf the 608 patients enrolled in the study undergoing 1- or 2-level decompression (23.0%, n = 140) or 1-level fusion (77.0%, n = 468), 14.5% (n = 88) were lost to follow-up at 2 years. Patients who were lost to follow-up were more likely to be younger (59.6 ± 13.5 vs 62.6 ± 11.7 years, p = 0.031), be employed (unemployment rate: 53.3% [n = 277] for successful follow-up vs 40.9% [n = 36] for those lost to follow-up, p = 0.017), have anxiety (26.1% [n = 23] vs 16.3% [n = 85], p = 0.026), have higher back pain scores (7.4 ± 2.9 vs 6.6 ± 2.8, p = 0.010), have higher leg pain scores (7.4 ± 2.5 vs 6.4 ± 2.9, p = 0.003), have higher Oswestry Disability Index scores (50.8 ± 18.7 vs 46 ± 16.8, p = 0.018), and have lower EQ-5D scores (0.481 ± 0.2 vs 0.547 ± 0.2, p = 0.012) at baseline.CONCLUSIONSTo execute future, high-quality studies, it is important to identify patients undergoing surgery for spondylolisthesis who might be lost to follow-up. In a large, prospective registry, the authors found that those lost to follow-up were more likely to be younger, be employed, have anxiety disorder, and have worse PRO scores.

OBJECTIVEMedical comorbidities, particularly preoperatively diagnosed anxiety, depression, and obesity, may influence how patients perceive and measure clinical benefit after a surgical intervention. The current study was performed to define and compare the minimum clinically important difference (MCID) thresholds in patients with and without preoperative diagnoses of anxiety or depression and obesity who underwent spinal fusion for grade 1 degenerative spondylolisthesis.METHODSThe Quality Outcomes Database (QOD) was queried for patients who underwent lumbar fusion for grade 1 degenerative spondylolisthesis during the period from January 2014 to August 2017. Collected patient-reported outcomes (PROs) included the Oswestry Disability Index (ODI), health status (EQ-5D), and numeric rating scale (NRS) scores for back pain (NRS-BP) and leg pain (NRS-LP). Both anchor-based and distribution-based methods for MCID calculation were employed.RESULTSOf 462 patients included in the prospective registry who underwent a decompression and fusion procedure, 356 patients (77.1%) had complete baseline and 12-month PRO data and were included in the study. The MCID values for ODI scores did not significantly differ in patients with and those without a preoperative diagnosis of obesity (20.58 and 20.69, respectively). In addition, the MCID values for ODI scores did not differ in patients with and without a preoperative diagnosis of anxiety or depression (24.72 and 22.56, respectively). Similarly, the threshold MCID values for NRS-BP, NRS-LP, and EQ-5D scores were not statistically different between all groups. Based on both anchor-based and distribution-based methods for determination of MCID thresholds, there were no statistically significant differences between all cohorts.CONCLUSIONSMCID thresholds were similar for ODI, EQ-5D, NRS-BP, and NRS-LP in patients with and without preoperative diagnoses of anxiety or depression and obesity undergoing spinal fusion for grade 1 degenerative spondylolisthesis. Preoperative clinical and shared decision-making may be improved by understanding that preoperative medical comorbidities may not affect the way patients experience and assess important clinical changes postoperatively.

Adult spinal deformity (ASD) is a diagnosis that encompasses heterogeneous disorders with an increasing prevalence. This increasing prevalence may be due to greater patient longevity or greater awareness of available treatments. Outcome assessment in ASD has evolved over the last 3 decades from physician-based assessments to a patient-centered perception of improvement. Outcome assessment that is reliable, accurate and responsive to change is especially important in ASD, as surgical treatment is known to carry a high cost and complication rate Glassman (Spine Deform 3:199–203, 2015); Glassman (Spine (Phila Pa 1976) 32: 2764–2770, 2007); Smith (J Neurosurg Spine 25:1–14, 2016). In an era of value-based care, diagnosis associated with such heterogeneity and high cost must provide sound evidence to support the cost versus outcome ratio. Numerous general health and disease specific patient-reported outcome measures (PROMs) have been utilized in ASD. We discuss these instruments in detail in the following state-of-the-art review.

OBJECTIVELumbar decompression without arthrodesis remains a potential treatment option for cases of low-grade spondylolisthesis (i.e., Meyerding grade I). Minimally invasive surgery (MIS) techniques have recently been increasingly used because of their touted benefits including lower operating time, blood loss, and length of stay. Herein, the authors analyzed patients enrolled in a national surgical registry and compared the baseline characteristics and postoperative clinical and patient-reported outcomes (PROs) between patients undergoing open versus MIS lumbar decompression.METHODSThe authors queried the Quality Outcomes Database for patients with grade I lumbar degenerative spondylolisthesis undergoing a surgical intervention between July 2014 and June 2016. Among more than 200 participating sites, the 12 with the highest enrollment of patients into the lumbar spine module came together to initiate a focused project to assess the impact of fusion on PROs in patients undergoing surgery for grade I lumbar spondylolisthesis. For the current study, only patients in this cohort from the 12 highest-enrolling sites who underwent a decompression alone were evaluated and classified as open or MIS (tubular decompression). Outcomes of interest included PROs at 2 years; perioperative outcomes such as blood loss and complications; and postoperative outcomes such as length of stay, discharge disposition, and reoperations.RESULTSA total of 140 patients undergoing decompression were selected, of whom 71 (50.7%) underwent MIS and 69 (49.3%) underwent an open decompression. On univariate analysis, the authors observed no significant differences between the 2 groups in terms of PROs at 2-year follow-up, including back pain, leg pain, Oswestry Disability Index score, EQ-5D score, and patient satisfaction. On multivariable analysis, compared to MIS, open decompression was associated with higher satisfaction (OR 7.5, 95% CI 2.41–23.2, p = 0.0005). Patients undergoing MIS decompression had a significantly shorter length of stay compared to the open group (0.68 days [SD 1.18] vs 1.83 days [SD 1.618], p < 0.001).CONCLUSIONSIn this multiinstitutional prospective study, the authors found comparable PROs as well as clinical outcomes at 2 years between groups of patients undergoing open or MIS decompression for low-grade spondylolisthesis.

STUDY DESIGN Prospective longitudinal cohort. OBJECTIVES The aim of this study was to determine whether functional treadmill testing (FTT) demonstrates differences between patients treated operatively and nonoperatively for adult symptomatic lumbar scoliosis (ASLS). SUMMARY OF BACKGROUND DATA ASLS has become increasingly prevalent as the population ages. ASLS can be accompanied by neurogenic claudication, leading to difficulty walking. FTT may provide a functional tool to evaluate patients with ASLS. METHODS One hundred and eighty-seven patients who underwent nonoperative (n = 88) or operative treatment (n = 99) of ASLS with complete baseline and 2-year post-treatment FTTs and concurrent patient-reported outcomes were identified. FTT parameters included maximum speed, time to onset of symptoms, distance ambulated, time ambulated, and Back and Leg pain severity before and after testing. RESULTS At baseline, patients treated operatively reported worse post-FTT back pain (4.39 vs. 3.45, P = 0.032) than those treated nonoperatively, despite similar ODI, SRS-22 Pain and Activity domain scores. Mean time ambulated (+2.15 vs. -1.20 P = 0.001), pre-FTT back pain (+0.19 vs. -1.60, P

STUDY DESIGN: Longitudinal Comparative Cohort OBJECTIVE: The purpose of this study is to report on the cost-effectiveness of surgical versus nonsurgical treatment for Adult Symptomatic Lumbar Scoliosis (ASLS) using the as-treated data and provide a comparison to previously reported intent-to-treat (ITT) analysis. SUMMARY OF BACKGROUND DATA: Adult spinal deformity is a relatively prevalent condition for which surgical treatment has become increasingly common but concerns surrounding complications, revision rates and cost-effectiveness remain unresolved. Of these issues, cost-effectiveness is perhaps the most difficult to quantify as the requisite data is difficult to obtain. The purpose of this study is to report on the cost-effectiveness of surgical versus nonsurgical treatment for Adult Symptomatic Lumbar Scoliosis (ASLS) using the as-treated data and provide a comparison to previously reported intent-to-treat (ITT) analysis. METHODS: Patients with at least five-year follow-up data within the same treatment arm were included. Data collected every three months included use of nonoperative modalities, medications and employment status. Costs for surgeries and non-operative modalities were determined using Medicare Allowable rates. Medication costs were determined using the RedBook and indirect costs were calculated based on reported employment status and income. Quality Adjusted Life Years (QALY) was determined using the SF-6D. RESULTS: Of 226 patients, 195 patients (73 Non-op, 122 Op) met inclusion criteria. At five years, 29 (24%) patients in the Op group had a revision surgery of whom two had two revisions and one had three revisions. The cumulative cost for the Op group was $111,451 with a cumulative QALY gain of 2.3. The cumulative cost for the Non-Op group was $29,124 with a cumulative QALY gain of 0.4. This results in an ICER of $44,033 in favor of Op treatment. CONCLUSION: This as-treated cost effectiveness analysis demonstrates that surgical treatment for adult lumbar scoliosis becomes favorable at year-three, one year earlier than suggested by a previous intent-to-treat analysis. LEVEL OF EVIDENCE: II

Study Design: Longitudinal cohort. Objectives: Posterior spinal fusion (PSF) using all-pedicle screw constructs has become the standard procedure in the treatment of adolescent idiopathic scoliosis (AIS). However, there have been several reports that all-pedicle screw constructs or the use of pedicle screws at the upper instrumented vertebrae (UIV) increases the incidence of proximal junctional kyphosis (PJK). We aimed to evaluate the impact of instrumentation type on the incidence of PJK following PSF for AIS. Methods: We performed a stratified random sampling from 3654 patients enrolled in a multicenter database of surgically treated AIS to obtain a representative sample from all Lenke types. Patients were then allocated into 3 groups based on the instrumentation type: all-pedicle screw (PS), hook at UIV with pedicle screws distally (HT), and hybrid constructs (HB). We measured proximal junctional angle (PJA) and defined PJK as PJA ≥ 10° and PJA progression of >10° at the final follow-up. Results: Fifteen (4.3%) of 345 cases had PJK. PJK was significantly more common in PS (11%) compared with HB (1%) and HT (0%) ( P < .001). PJK patients were similar to non-PJK patients regarding age, sex, curve type, UIV, and preoperative coronal Cobb angle. Thoracic kyphosis was significantly higher in the PJK group before surgery. Patients who developed PJK had a statistically significantly larger negative sagittal balance compared with the non-PJK group. Conclusion: The incidence of PJK was 4.3% and was more common in all-pedicle screw constructs. Using hooks at UIV might be a treatment strategy to limit PJK.

BACKGROUND The factors driving the best outcomes following minimally invasive surgery (MIS) for grade 1 degenerative lumbar spondylolisthesis are not clearly elucidated. OBJECTIVE To investigate the factors that drive the best 24-mo patient-reported outcomes (PRO) following MIS surgery for grade 1 degenerative lumbar spondylolisthesis. METHODS A total of 259 patients from the Quality Outcomes Database lumbar spondylolisthesis module underwent single-level surgery for degenerative grade 1 lumbar spondylolisthesis with MIS techniques (188 fusions, 72.6%). Twenty-four-month follow-up PROs were collected and included the Oswestry disability index (ODI) change (ie, 24-mo minus baseline value), numeric rating scale (NRS) back pain change, NRS leg pain change, EuroQoL-5D (EQ-5D) questionnaire change, and North American Spine Society (NASS) satisfaction questionnaire. Multivariable models were constructed to identify predictors of PRO change. RESULTS The mean age was 64.2 ± 11.5 yr and consisted of 148 (57.1%) women and 111 (42.9%) men. In multivariable analyses, employment was associated with superior postoperative ODI change (β-7.8; 95% CI [-12.9 to -2.6]; P = .003), NRS back pain change (β -1.2; 95% CI [-2.1 to -0.4]; P = .004), EQ-5D change (β 0.1; 95% CI [0.01-0.1]; P = .03), and NASS satisfaction (OR = 3.7; 95% CI [1.7-8.3]; P

OBJECTIVEThe Scoliosis Research Society-22r questionnaire (SRS-22r) has been shown to be reliable, valid, and responsive to change in patients with adult spinal deformity (ASD) undergoing surgery. The minimal clinically important difference (MCID) is the smallest difference in a health-related quality of life score that is considered to be worthwhile or clinically important to the individual. The authors hypothesized that the proportion of patients with ASD achieving an MCID in the SRS-22r score would be different between two culturally different cohorts. The purpose of this study was to compare the proportion of patients with ASD achieving MCID for the SRS-22r domains in North American (NA) and Japanese cohorts.METHODSA total of 137 patients from North America (123 women, mean age 60.0 years) and 60 patients from Japan (56 women, mean age 65.5 years) with at least 2 years of follow-up after corrective spine surgery for ASD were included. Except for self-image, published Japanese MCID values of SRS-22r for ASD were higher (function = 0.90, pain = 0.85, self-image = 1.05, subtotal = 1.05) than the published NA MCID values (function = 0.60, pain = 0.40, self-image = 1.23, subtotal = 0.43).RESULTSThere was a statistically significant improvement in all SRS-22r domain scores at 2 years compared to baseline in both cohorts. Except for mental health (NA = 0.32, Japanese = 0.72, p = 0.005), the mean improvement from baseline to 2 years was similar between the NA and Japanese cohorts. The proportion of patients achieving MCID was higher in North America for function (NA = 51%, Japanese = 30%, p = 0.006), pain (NA = 80%, Japanese = 47%, p < 0.001), and subtotal (NA = 72%, Japanese = 35%, p < 0.001), while there was no significant difference for self-image (NA = 53%, Japanese = 58%, p = 0.454).CONCLUSIONSDespite similar improvements in SRS-22r domain scores from baseline to 2 years postoperatively, the proportion of patients reaching SRS-22r MCID for function, pain, and subtotal after ASD surgery was higher in the NA cohort than in the Japanese cohort. This may imply that patients in North America and Japan may value observed changes in clinical status differently.

Regional differences in outcomes after spine surgery are poorly understood. We assessed disability and quality-of-life outcomes by geographic region in the United States using the NeuroPoint Alliance Quality Outcomes Database.We queried the prospective Quality Outcomes Database patient registry to identify patients who underwent elective 1- or 2-level lumbar surgery for grade I degenerative spondylolisthesis from July 2014 through June 2016. Primary outcome measures included Oswestry Disability Index (ODI) and EuroQOL-5D (EQ-5D) reported at 24 months postoperatively. Differences in EQ-5D and ODI were compared across geographic regions of the United States (Northeast, Midwest, South, West).We identified 608 patients from 12 centers who underwent surgery. Of these, 517 (85.0%) had ODI data and 492 (80.9%) had EQ-5D data at 24 months. Southern states had the largest representation (304 patients; 5 centers), followed by Northeastern (114 patients; 3 centers), Midwestern (96 patients; 2 centers), and Western (94 patients; 2 centers) states. Baseline ODI scores were significantly different among regions, with the South having the greatest baseline disability burden (Northeast: 40.9 ± 16.9, South: 51.2 ± 15.8, Midwest: 40.9 ± 17.8, West: 45.0 ± 17.1, P0.001). The change in ODI at 24 months postoperatively was significantly different among regions, with the South showing the greatest ODI improvement (Northeast: -21.1 ± 18.2, South: -26.5 ± 20.2, Midwest: -18.2 ± 22.9, West: -21.7 ± 19.6, P0.001). All regions had ≥60% achievement of the minimum clinically important difference in ODI at 24 months postoperatively. No regional differences were observed for EQ-5D.Significant regional variation exists for disability outcomes, but not quality of life, at 24 months after spinal surgery for grade I degenerative spondylolisthesis.

OBJECTIVEDischarge to an inpatient rehabilitation facility or another acute-care facility not only constitutes a postoperative challenge for patients and their care team but also contributes significantly to healthcare costs. In this era of changing dynamics of healthcare payment models in which cost overruns are being increasingly shifted to surgeons and hospitals, it is important to better understand outcomes such as discharge disposition. In the current article, the authors sought to develop a predictive model for factors associated with nonroutine discharge after surgery for grade I spondylolisthesis.METHODSThe authors queried the Quality Outcomes Database for patients with grade I lumbar degenerative spondylolisthesis who underwent a surgical intervention between July 2014 and June 2016. Only those patients enrolled in a multisite study investigating the impact of fusion on clinical and patient-reported outcomes among patients with grade I spondylolisthesis were evaluated. Nonroutine discharge was defined as those who were discharged to a postacute or nonacute-care setting in the same hospital or transferred to another acute-care facility.RESULTSOf the 608 patients eligible for inclusion, 9.4% (n = 57) had a nonroutine discharge (8.7%, n = 53 discharged to inpatient postacute or nonacute care in the same hospital and 0.7%, n = 4 transferred to another acute-care facility). Compared to patients who were discharged to home, patients who had a nonroutine discharge were more likely to have diabetes (26.3%, n = 15 vs 15.7%, n = 86, p = 0.039); impaired ambulation (26.3%, n = 15 vs 10.2%, n = 56, p < 0.001); higher Oswestry Disability Index at baseline (51 [IQR 42–62.12] vs 46 [IQR 34.4–58], p = 0.014); lower EuroQol-5D scores (0.437 [IQR 0.308–0.708] vs 0.597 [IQR 0.358–0.708], p = 0.010); higher American Society of Anesthesiologists score (3 or 4: 63.2%, n = 36 vs 36.7%, n = 201, p = 0.002); and longer length of stay (4 days [IQR 3–5] vs 2 days [IQR 1–3], p < 0.001); and were more likely to suffer a complication (14%, n = 8 vs 5.6%, n = 31, p = 0.014). On multivariable logistic regression, factors found to be independently associated with higher odds of nonroutine discharge included older age (interquartile OR 9.14, 95% CI 3.79–22.1, p < 0.001), higher body mass index (interquartile OR 2.04, 95% CI 1.31–3.25, p < 0.001), presence of depression (OR 4.28, 95% CI 1.96–9.35, p < 0.001), fusion surgery compared with decompression alone (OR 1.3, 95% CI 1.1–1.6, p < 0.001), and any complication (OR 3.9, 95% CI 1.4–10.9, p < 0.001).CONCLUSIONSIn this multisite study of a defined cohort of patients undergoing surgery for grade I spondylolisthesis, factors associated with higher odds of nonroutine discharge included older age, higher body mass index, presence of depression, and occurrence of any complication.

Expert opinion-modified Delphi study.We used a modified Delphi approach to obtain consensus among leading spinal deformity surgeons and their neuroanesthesiology teams regarding optimal practices for obtaining reliable motor evoked potential (MEP) signals.Intraoperative neurophysiological monitoring of transcranial MEPs provides the best method for assessing spinal cord integrity during complex spinal surgeries. MEPs are affected by pharmacological and physiological parameters. It is the responsibility of the spine surgeon and neuroanesthesia team to understand how they can best maintain high-quality MEP signals throughout surgery. Nevertheless, varying approaches to neuroanesthesia are seen in clinical practice.We identified 19 international expert spinal deformity treatment teams. A modified Delphi process with two rounds of surveying was performed. Greater than 50% agreement on the final statements was considered "agreement";75% agreement was considered "consensus."Anesthesia regimens and protocols were obtained from the expert centers. There was a large amount of variability among centers. Two rounds of consensus surveying were performed, and all centers participated in both rounds of surveying. Consensus was obtained for 12 of 15 statements, and majority agreement was obtained for two of the remaining statements. Total intravenous anesthesia was identified as the preferred method of maintenance, with few centers allowing for low mean alveolar concentration of inhaled anesthetic. Most centers advocated for150 μg/kg/min of propofol with titration to the lowest dose that maintains appropriate anesthesia depth based on awareness monitoring. Use of adjuvant intravenous anesthetics, including ketamine, low-dose dexmedetomidine, and lidocaine, may help to reduce propofol requirements without negatively effecting MEP signals.Spine surgeons and neuroanesthesia teams should be familiar with methods for optimizing MEPs during deformity and complex spinal cases. Although variability in practices exists, there is consensus among international spinal deformity treatment centers regarding best practices.5.

Study design Secondary analysis of subjects in the control anterior cervical discectomy and fusion (ACDF) arm of Medtronic Investigational Device Exemption (IDE) trials for cervical disc arthroplasty (CDA). Objectives To compare patient-reported outcomes (PROs) in patients with radiographic nonunion to patients with a solid fusion. Summary of background data The true prevalence of nonunion after ACDF is unknown. Nonunion may be under-reported, as some patients are not symptomatic enough to justify radiographic evaluation. Methods Three hundred forty-five subjects enrolled in the control arm of IDE trials for CDA who had single-level ACDF with allograft and plate with 24 month data formed the study cohort. Using the 24-month postop evaluation, subjects were divided into those who had radiographic fusion and those who did not using strict study criteria. SF-36, NDI, Neck and Arm pain NRS scores were reported at 12, 24, 36, 60, and 84 months postop. For subjects who had secondary surgery failures, the last observations before the secondary surgery were carried forward to future visits for the analysis. Results Forty-four (13%) patients had radiographic nonunion and 301 (87%) were fused at 24 months postop. At 24 months, PROs were similar between the two groups. Seven patients in the Nonunion group (16%) and 10 (3%) in the Fused group had additional surgery at the index level prior to the 24 follow-up (P = 0.003). Over the 84-month follow-up a total of 9 patients in the Nonunion group (21%) and 22 (7%) in the Fused group had additional surgery at the index level (P = 0.009). Conclusion While the radiographic nonunion rate at 24 months was 13%, PROs show that many of the radiographic nonunions were asymptomatic. Although the majority of patients with radiographic nonunion did not undergo additional surgery, the rate of secondary surgeries at the index level was significantly higher in the radiographic nonunion group. Level of evidence 2.

OBJECTIVEThe midline transforaminal lumbar interbody fusion (MIDLIF) using cortical screw fixation is a novel, minimally invasive procedure that may offer enhanced recovery over traditional open transforaminal lumbar interbody fusion (TLIF). Little information is available regarding the comparative cost-effectiveness of the MIDLIF over conventional TLIF. The purpose of this study was to compare cost-effectiveness of minimally invasive MIDLIF with open TLIF.METHODSFrom a prospective, multisurgeon, surgical database, a consecutive series of patients undergoing 1- or 2-level MIDLIF for degenerative lumbar conditions was identified and propensity matched to patients undergoing TLIF based on age, sex, smoking status, BMI, diagnosis, American Society of Anesthesiologists Physical Status Classification System (ASA) class, and levels fused. Direct costs at 1 year were collected, including costs associated with the index surgical visit as well as costs associated with readmission. Improvement in health-related quality of life was measured using EQ-5D and SF-6D.RESULTSOf 214 and 181 patients undergoing MIDLIF and TLIF, respectively, 33 cases in each cohort were successfully propensity matched. Consistent with propensity matching, there was no difference in age, sex, BMI, diagnosis, ASA class, smoking status, or levels fused. Spondylolisthesis was the most common indication for surgery in both cohorts. Variable direct costs at 1 year were $2493 lower in the MIDLIF group than in the open TLIF group (mean $15,867 vs $17,612, p = 0.073). There was no difference in implant (p = 0.193) or biologics (p = 0.145) cost, but blood utilization (p = 0.015), operating room supplies (p < 0.001), hospital room and board (p < 0.001), pharmacy (p = 0.010), laboratory (p = 0.004), and physical therapy (p = 0.009) costs were all significantly lower in the MIDLIF group. Additionally, the mean length of stay was decreased for MIDLIF as well (3.21 vs 4.02 days, p = 0.05). The EQ-5D gain at 1 year was 0.156 for MIDLIF and 0.141 for open TLIF (p = 0.821). The SF-6D gain at 1 year was 0.071 for MIDLIF and 0.057 for open TLIF (p = 0.551).CONCLUSIONSCompared with patients undergoing traditional open TLIF, those undergoing MIDLIF have similar 1-year gains in health-related quality of life, with total direct costs that are $2493 lower. Although the findings were not statistically significant, minimally invasive MIDLIF showed improved cost-effectiveness at 1 year compared with open TLIF.

Background In 2011, studies suggested that complications and cancer rates associated with bone morphogenetic protein (BMP) were greater than previously reported. However, later studies reported complication rates similar to prior literature and no increased cancer rate. We evaluated the pattern of clinical utilization of BMP in posteriorly based lumbar fusion by comparing two periods: 2002-2004 and 2017-2019. Methods Patients who received BMP from 2002-2004 (Early) and 2017-2019 (Late) from a single multi-surgeon institution who had a lumbar fusion were identified. One hundred patients from each cohort were randomly selected. Mean total BMP used at each level and the proportion of BMP placed in the interbody space versus posterolateral gutters were evaluated. Results In the transforaminal lumbar intebody fusion (TLIF) cohort, the total BMP dose in the Late group (6.15 mg) was nearly half of that used in the Early group (12.04 mg, p

Background Temperature elevation, a classic marker of infection and local temperature elevation, might be a useful predictor of early infection. However temperature measurement around the spine is not readily accessible. The purpose of this study was to explore whether a temperature sensing implant might reproducibly detect local temperature change associated with peri-implant wound infection, in a rabbit model. Methods Twelve adult rabbits were implanted with a spinal screw-rod construct. Temperature probes were placed at the implantation site as well as at a separate scapular site away from the surgical site to serve as control. Animals were inoculated with S. aureus: group 1 (saline control), group 2 (low dose 1 × 102 CFU/site), group 3 (medium dose 1 × 104 CFU/site), and group 4 (high dose 1 × 106 CFU/site) and monitored for 7 days prior to euthanasia. Results The scapular control temperature and implant site temperature in the non-infected animals remained similar throughout the study period. Both the scapular control and implant site temperatures were elevated in the infected animals compared to the non-infected animals. There was a statistically significant difference in the scapular control temperature and implant site temperature in all infected animals but not in the non-infected animals. Difference in temperature elevation between implant site and control scapular site were greatest for the animals with worst clinical appearance during the post-mortem evaluation. Conclusions This rabbit model demonstrates that local temperature measured in proximity to a spinal implant is elevated in the presence of infection with greater elevations associated with worse infections. Availability of an implantable temperature sensor may yield valuable information for the assessment and treatment of suspected spinal wound infection in the clinical setting.

Background Context In patients with lumbar spinal stenosis, it is crucial for clinicians to identify all symptomatic levels. Prior studies have demonstrated that CT-Myelo has a greater sensitivity in revealing stenosis (94.4%) compared to MRI (75.9%). However, this is an invasive test that should be used judiciously. No study has identified subgroups of patients that do or do not benefit from this additional invasive testing. Purpose The objective of this study was to identify subgroups of patients with lumbar stenosis for whom CT myelogram could be expected to provide additional information following an MRI scan. Study Design Retrospective Chart Review Study Sample Consecutive series of patients with lumbar degenerative disease seen at a single multi-surgeon tertiary spine center. Outcome measures Degree of stenosis on MRI or CT-myelo Methods Medical records were reviewed to collect standard demographic and surgical data and patient diagnoses. MRI and CT-Myelo obtained within six months of each other in patients >45 years old with a diagnosis of central stenosis, spondylolisthesis or degenerative scoliosis were reviewed. Each lumbar level was recorded as mild, moderate, or severe based on the radiologist's report. Fisher exact test was performed with change in recorded severity of stenosis from MRI to CT-Myelo as the primary outcome of interest. Results Of 269 patients, 207 (80%) had at least one level of moderate or severe central stenosis on MRI and 62 had mild or no stenosis on MRI. Of the 207, 139 (67%) had multilevel stenosis and 68 (33%) had single level stenosis. CT-Myelo identified a greater proportion of additional stenotic levels in patients with multilevel stenosis (80/139, 58%) compared to patients with single-level stenosis (27/68, 40%, p=0.018). In 62 patients with a clinical diagnosis of lumbar stenosis but no moderate to severe stenosis on MRI, CT myelogram identified three additional stenotic levels (3/65, 5%, p=0.836). Conclusion CT Myelography is not as useful in providing additional information in patients with no stenosis or single level stenosis as compared to patients with multilevel stenosis.

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: Adult spinal deformity (ASD) is a prevalent condition in individuals over the age of 65; leading to impaired standing balance and abnormal gait patterns. This functional impairment may be due to the fixed sagittal or coronal malalignment; associated spinal stenosis or deconditioning. The Berg balance scale (BBS) was developed to measure balance by assessing the performance of functional tasks. The purpose of this study is to determine if BBS is a useful metric for evaluating functional status in ASD patients. Methods: ASD patients who required fusion from the thoracic spine to the pelvis from 2014 to 2016 were enrolled and asked to complete the BBS prior to and six months after surgery. BBS were obtained by a certified physical therapist. Standard demographic; radiographic and surgical data were collected. The Oswestry disability index (ODI), EuroQOL-5D and numeric rating scales (0 to 10) for back and leg pain were assessed at baseline and post-intervention. Results: Of 21 patients enrolled; 19 completed pre- and post-surgery BBS. The mean age was 59.8±13.3 years with 14 females. There was a statistically significant improvement in all outcome scores and radiographic parameters after surgery; but no difference in BBS. Only one patient had a BBS score low enough to be considered a medium fall risk. There was no difference in the pre-op BBS scores in the four patients that had revision surgery compared to those that did not. Conclusions: In this small pilot study; BBS did not appear to be associated with measures of clinical and radiographic improvement in ASD patients. The test was also potentially problematic in that it has a ceiling effect and required significant time with a trained physical therapist for administration. Continued effort to identify a viable measure of balance dysfunction in ASD patients is warranted.

STUDY DESIGN Secondary analysis of prospective multicenter cohort. OBJECTIVE To assess effect of serious adverse events (SAEs) on 2- and 4-year patient-reported outcomes measures (PROMs) in patients surgically treated for adult symptomatic lumbar scoliosis (ASLS). SUMMARY OF BACKGROUND DATA Operative treatment for ASLS can improve health-related quality of life, but has high rates of SAEs. How these SAEs effect health-related quality of life remain unclear. METHODS The ASLS study assessed operative versus nonoperative ASLS treatment, with randomized and observational arms. Patients were 40- to 80-years-old with ASLS, defined as lumbar coronal Cobb ≥30° and Oswestry Disability Index (ODI) ≥20 or Scoliosis Research Society-22 (SRS-22) ≤4.0 in pain, function, and/or self-image domains. SRS-22 subscore and ODI were compared between operative patients with and without a related SAE and nonoperative patients using an as-treated analysis combining randomized and observational cohorts. RESULTS Two hundred eighty-six patients were enrolled, and 2- and 4-year follow-up rates were 90% and 81%, respectively, although at the time of data extraction not all patients were eligible for 4-year follow-up. A total of 97 SAEs were reported among 173 operatively treated patients. The most common were implant failure/pseudarthrosis (n = 25), proximal junctional kyphosis/failure (n = 10), and minor motor deficit (n = 8). At 2 years patients with an SAE improved less than those without an SAE based on SRS-22 (0.52 vs. 0.79, P = 0.004) and ODI (-11.59 vs. -17.34, P = 0.021). These differences were maintained at 4-years for both SRS-22 (0.51 vs. 0.86, P = 0.001) and ODI (-10.73 vs. -16.69, P = 0.012). Despite this effect, patients sustaining an operative SAE had greater PROM improvement than nonoperative patients (P

OBJECTIVEThe optimal minimally invasive surgery (MIS) approach for grade 1 lumbar spondylolisthesis is not clearly elucidated. In this study, the authors compared the 24-month patient-reported outcomes (PROs) after MIS transforaminal lumbar interbody fusion (TLIF) and MIS decompression for degenerative lumbar spondylolisthesis.METHODSA total of 608 patients from 12 high-enrolling sites participating in the Quality Outcomes Database (QOD) lumbar spondylolisthesis module underwent single-level surgery for degenerative grade 1 lumbar spondylolisthesis, of whom 143 underwent MIS (72 MIS TLIF [50.3%] and 71 MIS decompression [49.7%]). Surgeries were classified as MIS if there was utilization of percutaneous screw fixation and placement of a Wiltse plane MIS intervertebral body graft (MIS TLIF) or if there was a tubular decompression (MIS decompression). Parameters obtained at baseline through at least 24 months of follow-up were collected. PROs included the Oswestry Disability Index (ODI), numeric rating scale (NRS) for back pain, NRS for leg pain, EuroQol-5D (EQ-5D) questionnaire, and North American Spine Society (NASS) satisfaction questionnaire. Multivariate models were constructed to adjust for patient characteristics, surgical variables, and baseline PRO values.RESULTSThe mean age of the MIS cohort was 67.1 ± 11.3 years (MIS TLIF 62.1 years vs MIS decompression 72.3 years) and consisted of 79 (55.2%) women (MIS TLIF 55.6% vs MIS decompression 54.9%). The proportion in each cohort reaching the 24-month follow-up did not differ significantly between the cohorts (MIS TLIF 83.3% and MIS decompression 84.5%, p = 0.85). MIS TLIF was associated with greater blood loss (mean 108.8 vs 33.0 ml, p < 0.001), longer operative time (mean 228.2 vs 101.8 minutes, p < 0.001), and longer length of hospitalization (mean 2.9 vs 0.7 days, p < 0.001). MIS TLIF was associated with a significantly lower reoperation rate (14.1% vs 1.4%, p = 0.004). Both cohorts demonstrated significant improvements in ODI, NRS back pain, NRS leg pain, and EQ-5D at 24 months (p < 0.001, all comparisons relative to baseline). In multivariate analyses, MIS TLIF—as opposed to MIS decompression alone—was associated with superior ODI change (β = −7.59, 95% CI −14.96 to −0.23; p = 0.04), NRS back pain change (β = −1.54, 95% CI −2.78 to −0.30; p = 0.02), and NASS satisfaction (OR 0.32, 95% CI 0.12–0.82; p = 0.02).CONCLUSIONSFor symptomatic, single-level degenerative spondylolisthesis, MIS TLIF was associated with a lower reoperation rate and superior outcomes for disability, back pain, and patient satisfaction compared with posterior MIS decompression alone. This finding may aid surgical decision-making when considering MIS for degenerative lumbar spondylolisthesis.

Background: The measurement of health-related quality of life is important in spinal deformity surgery. The Scoliosis Research Society questionnaire has allowed disease-specific research in this area, and determining the minimal clinically important difference (MCID) is as important as it is elusive. We seek to further refine our estimations of clinically perceived improvements by the patient. Methods: We used an anchor-based approach for each domain of the SRS questionnaire to compare changes at 1 year after treatment. We set the MCID as the upper 95% boundary of the “no change” group bordering the “improvement” arm, where the patients may start to perceive their own change toward the better. We compared this with the mean change. Results: The threshold value for the MCID was 0.54 for the pain domain, 0.31 for function, 0.62 for self-image, and 0.5 for mental health. The mean changes in our group9s pain and self-image exceeded their MCID. Conclusions: Compared with our previous work, we further attempted to refine our assessment of the MCID in spinal deformity. Pain continues to show clinically significant improvement, and self-image also demonstrated mean improvement over its estimated MCID. Level of Evidence: 2 Clinical Relevance: This result in self-image is an important addition to the MCID literature, given its lack of consistency in previous work.

BACKGROUND CONTEXT Health literacy, defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions,” has been demonstrated to affect access to care and appropriate healthcare utilization. PURPOSE To determine the impact of health literacy in the evaluation and management of patients with chronic low back pain. STUDY DESIGN Cross sectional. PATIENT SAMPLE Patients seen at a multisurgeon spine specialty clinic. OUTCOME MEASURES Oswestry Disability Index, EQ-5D, and Numeric Rating Scales (0–10) for back and leg pain. METHODS The Newest Vital Sign (NVS) and Health Literacy Survey, Oswestry Disability Index, EQ-5D and pain scales were administered to patients undergoing evaluation and treatment for lumbar degenerative disease in the outpatient setting. Patients were surveyed regarding their use of medication, therapy, and pain management modalities. RESULTS Of 201 patients approached for participation, 186 completed the health literacy surveys. Thirty (17%) were assessed as having limited literacy, 52 (28%) as possibly having limited literacy and 104 (56%) having adequate literacy based on their NVS scores. The cohort with low NVS scores also had low Health Literacy Survey Scores. Patients with limited literacy had worse back and leg pain scores compared with patients with possibly limited literacy and adequate literacy. Patients with adequate health literacy were more likely to use medications (80% vs. 53%, p = .017) and were more likely to see a specialist (34% vs. 17%) compared with those with limited literacy. Patients with limited health literacy were not more likely to see a chiropractor (7% vs. 7%), but reported more visits (19 vs. 8). CONCLUSIONS Patients with lower health literacy reported worse back and leg pain scores, indicating either more severe disease or a fundamental difference in their responses to standard health-related quality of life measures. This study also suggests that patients with limited health literacy may underutilize some resources and overutilize other resources. Further study is needed to clarify these patterns, and to examine their impact on health status and clinical outcomes.

UpdateThis article was updated on November 12, 2019, because of a previous error. On page 349, in Table VII, the column heads “2 Yr”, “Mean Change from Baseline (SE)”, “Difference in Mean Change (95% CI)”, and “P Value” that had been aligned with the content in the second to fourth columns have now

Study Design: Medicare database analysis. Objective: The purpose of this study was to investigate whether neurologic disorders represent a risk factor for revision after lumbar spine surgery. Methods: Patients who underwent lumbar spine surgery were identified from 5% Medicare Part B claims between 2005 and 2008. Cox regression analysis was used to evaluate risk factors for revision within the 7 years after the index lumbar surgery. Covariates included age, gender, race, census region, Medicare buy-in status, Charlson score, year, prior lumbar fusion within 2 years of index surgery, prior diagnosis of cervical spondylotic myelopathy treated with or without cervical spine surgery, and diagnoses of other neuromuscular conditions. Results: Of 8665 cases who had decompression only, 401 (5%) had a revision within 7 years after the index surgery. Factors predictive of revision were prior lumbar fusion (hazard ratio [HR] = 2.78, confidence interval [CI] = 1.43-5.37, P = .002) and being female (HR = 1.61, CI = 1.31-1.97, P < .001). Of 5501 cases who had a decompression and fusion, 752 (14%) had a revision surgery within 7 years after the index surgery. Factors predictive of revision were the presence of a neurologic disorder (HR = 1.24, CI = 1.05-1.46, P = .010), prior lumbar fusion (HR = 3.09, CI = 2.05-4.63, P < .001), and being female (HR = 1.35, CI = 1.15-1.57, P < .001). Conclusions: An increase in revision rate ( P = 0.01, HR = 1.24) was seen in patients with neurologic disorders undergoing lumbar decompression and fusion, although not for patients undergoing decompression alone. This suggests an opportunity to improve clinical outcome and reduce revision rate through improved surgical decision making or treatment of the neurologic disorder.

Background Context There are situations that require the replacement of pedicle screws. They are often exchanged when loose or broken or to accommodate a different sized rod or pedicle screw system. Traditionally, pedicle screws are replaced by up-sizing the core diameter until an interference fit is obtained. However, this method carries a risk of pedicle screw breach. Purpose To determine if dual pitch screws, with cancellous pitch in the vertebral body and cortical pitch throughout the pedicle, allows for in-line screw revision without upsizing screw diameter. Study Design Cadaveric biomechanical Study Patient Sample Not applicable Outcome Measures Not applicable Methods Pedicle screws were tested in the lumbar vertebrae from eleven cadavers. Standard pitch 5.5 mm screws were inserted and loaded using a "break-in" protocol. Screws were removed and replaced with one of four screw types: 5.5 mm Standard Pitch, 5.5 mm Dual Pitch, 6.0 mm Standard Pitch, or 6.0 mm Dual Pitch. Failure testing was done using a stepwise increasing cyclic loading protocol for 100 cycles at each increasing load level. The loading consisted of a combined axial and bending load simulating the load seen by the most inferior screw. Results Failure was consistent, with the tip of the screw displacing inferiorly into the vertebral body while simultaneously pulling out. Failure strength was lowest in the 5.5mm Standard (135.8±29.4N) followed by 6.0mm Standard (141.8±38.6N), 5.5mm Dual (158.1±53.8N), and 6.0mm Dual (173.6±52.1N, p=.023). There was no difference in the failure strength between the 5.5mm Dual and 6.0mm Standard. Lumbar level (p=.701) and donor spine (p=.062) were not associated with failure strength. Conclusions After pedicle screw removal, screws with a larger core diameter or with a dual pitch have similar failure strengths. Dual pitch screws may allow for in-line revision of screws without upsizing screw diameter, minimizing the risk of pedicle breach or fracture. Clinical Significance Dual pitch screws, with cancellous pitch in the vertebral body and cortical pitch through the pedicle, allows for in-line revision of pedicle screws without upsizing screw diameter; reducing the risk of pedicle breach or fracture when exchanging screws.

BACKGROUND CONTEXT Surgical decision-making for cervical spondylotic myelopathy (CSM) relies on evaluation of symptoms and physical examination. The Romberg test is a clinical exam used to identify balance issues with CSM. However, the Romberg test has a subjective interpretation and has a binary (positive or negative) result. While previous studies showed that force plate pressure readings provide quantitative measurements that objectively identify poor postural control in patients with CSM, the study compared an older CSM patient cohort with a significantly younger normal cohort, failing to account for regular aging changes. PURPOSE This study aims to compare force plate pressure readings during a standard Romberg test in patients with CSM to age-matched normal healthy volunteers. STUDY DESIGN/SETTING Longitudinal observational comparative cohort from a single multisurgeon spine center. PATIENT SAMPLE Patients who were clinically diagnosed with CSM (mean age 54.8 years, N=27) were compared to age-matched healthy volunteers (mean age 54.4 years, N=27) without a clinical history of cervical pathology. OUTCOME MEASURES Quantitative Romberg Force Plate Measurements. METHODS Patients with CSM requiring surgery and healthy normal volunteers were asked to perform the Romberg test while on a force plate measuring the center of pressure (COP): standing up straight with arms extended for 30 seconds with eyes open, followed by 30 seconds with eyes closed. The change for sway area, sway frequency and sway speed with eyes closed and eyes open were calculated and compared between patients with CSM and healthy volunteers. RESULTS Twenty-seven of 48 CSM patients were age-matched to 27 healthy volunteers. There was a larger change in Romberg measurements with eyes open vs eyes closed in CSM patients compared to normal volunteers for maximum lateral movement (12.1mm2 vs 4.1mm2, p CONCLUSIONS Poor standing balance can be quantified in patients with CSM. Quantifying standing balance in patients with CSM shows significantly worse objective measures than age-matched healthy volunteers. The Romberg test on a force plate may help diagnose and evaluate patients with CSM, guide patient management, potentially grade the severity of spinal pathology, allow more timely surgical intervention, and improve surgical outcomes. Further studies are needed to determine its utility in monitoring disease progression and measure treatment effectiveness. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Study Design: A retrospective study. Objectives: Curve flexibility in patients with adolescent idiopathic scoliosis (AIS) can be evaluated using different techniques. This study aimed to determine whether the combination of side-bending (SB) and traction (TX) radiographs influences preoperative planning for AIS than either radiograph alone. Methods: Thirty-two spine surgeons were asked to review 30 AIS Lenke type 1 cases and select an upper instrumented vertebra (UIV) and lower instrumented vertebra (LIV) for the posterior spinal instrumentation of each case. Each rater reviewed the cases 3 times in each round. The raters were provided with the full-length posteroanterior (PA) and lateral standing and SB radiographs for round 1; PA, lateral, and TX radiographs for round 2; and PA, lateral, SB, and TX radiographs for round 3. Intra- and inter-rater reliabilities were evaluated using Kappa statistics. Results: The intra-rater reliability for UIV and LIV was 0.657 and 0.612 between rounds 1 and 2, 0.634 and 0.692 between rounds 1 and 3, and 0.659 and 0.638 between rounds 2 and 3, respectively, which indicated substantial agreement between rounds. The inter-rater kappa reliabilities for UIV and LIV selection were 0.103 and 0.412 for round 1, 0.121 and 0.380 for round 2, and 0.125 and 0.368 for round 3, indicating slight to moderate agreement between raters. Conclusions: Whether raters used either SB or TX radiography, or both in addition to PA and lateral standing radiographs, did not influence the decision making for UIV or LIV of AIS Lenke type 1 surgery.

Background With the current opioid crisis, as many as 38% of patients are still on opioids one year after elective spine surgery. Identifying drivers of in-hospital opioid consumption may decrease subsequent opioid dependence. We aimed to identify the drivers of in-hospital opioid consumption in patients undergoing 1-2-level instrumented lumbar fusions. Methods This is a retrospective cohort study. Electronic medical record analysts identified consecutive patients undergoing 1-2 level instrumented lumbar fusions for degenerative lumbar conditions from 2016 to 2018 from a single-center hospital administrative database. Oral, intravenous, and transdermal opioid dose administrations were converted to morphine milligram equivalents (MME). Linear regression analysis was used to determine associations between postoperative day (POD) 4 cumulative in-hospital MMEs and the patients' baseline characteristics including body mass index (BMI), race, American Society of Anesthesiologists (ASA) grade, smoking status, marital status, insurance type, zip code, number of fused levels, approach and preoperative opioid use. Results A total of 1,502 patients were included. The mean cumulative MMEs at POD 4 was 251.5. Linear regression analysis yielded four drivers including younger age, preoperative opioid use, current smokers and more levels fused. There were no associations with surgical approach, zip code, ASA grade, marital status, BMI, race or insurance type. Conclusions Use of preoperative opioids and smoking are modifiable risk factors for higher in-hospital opioid consumption and can be targets for intervention prior to surgery in order to decrease in-hospital opioid use.

BACKGROUND Trials of lumbar spondylolisthesis are difficult to compare because of the heterogeneity in the populations studied. OBJECTIVE To define patterns of clinical presentation. METHODS This is a study of the prospective Quality Outcomes Database spondylolisthesis registry, including patients who underwent single-segment surgery for grade 1 degenerative lumbar spondylolisthesis. Twenty-four-month patient-reported outcomes (PROs) were collected. A k-means clustering analysis-an unsupervised machine learning algorithm-was used to identify clinical presentation phenotypes. RESULTS Overall, 608 patients were identified, of which 507 (83.4%) had 24-mo follow-up. Clustering revealed 2 distinct cohorts. Cluster 1 (high disease burden) was younger, had higher body mass index (BMI) and American Society of Anesthesiologist (ASA) grades, and globally worse baseline PROs. Cluster 2 (intermediate disease burden) was older and had lower BMI and ASA grades, and intermediate baseline PROs. Baseline radiographic parameters were similar (P > .05). Both clusters improved clinically (P

Purpose Symptomatic adult spinal deformity (ASD) with an extremely variable presentation with pain, with and without neurogenic leg pain, and/or disturbed sagittal and coronal balance, causes a significant societal burden of disease. It is an important consequence of the aging adult population, generating a plethora of spine-related interventions with variable treatment efficacy and consistently high costs. Recent years have witnessed more than a threefold increase in the prevalence and treatment of ASD, and further increases over the coming decades are expected with the growing elderly population worldwide. The ability to monitor and assess clinical outcomes has not kept pace with these developments. This paper addresses the pressing need to provide a set of common outcome metrics for this growing group of patients with back pain and other disabilities due to an adult spinal deformity. Methods The standard outcome set was created by a panel with global representation, using a thorough modified Delphi procedure. The three-tiered outcome hierarchy (Porter) was used as a framework to capture full cycle of care. The standardized language of the International Classification of Functioning, Disability and Health (WHO-ICF) was used. Results Consensus was reached on a core set of 25 WHO-ICF outcome domains (‘What to measure’); on the accompanying globally available clinician and patient reported measurement instruments and definitions (‘How to measure’), and on the timing of the measurements (‘When to measure’). The current work has brought to light domains not routinely reported in the spinal literature (such as pulmonary function, return to work, social participation), and domains for which no adequate instruments have yet been identified (such as how to clinically quantify in routine practice lumbar spinal stenosis, neurogenic claudication, radicular pain, and loss of lower extremity motor function). Conclusion A standard outcome set was developed for patients undergoing treatment for adult spinal deformity using globally available outcome metrics. The current framework can be considered a reference for further work, and may provide a starting point for routine methodical and systematic monitoring of outcomes. Post-COVID e-health may accelerate the routine capture of these types of data.

BACKGROUND CONTEXT The recent opioid crisis in the US highlights opioid related side-effects and the dire need to reduce opioid exposure with alternative approaches. Prior studies reported that as many as 25% of opioid naive patients undergoing lumbar fusion surgery are still consuming opioids at 2 years postoperative. Currently, opioids are a primary component of anesthesia during spinal surgery. We developed an opioid sparing anesthesia (OSA) protocol for lumbar spinal fusion surgery to mitigate opioid exposure. PURPOSE To compare surgical, peri- and postoperative process measures and in-hospital opioid consumption in patients receiving OSA vs traditional anesthesia. STUDY DESIGN/SETTING Retrospective, single center propensity-matched observational cohort study. PATIENT SAMPLE Patients who underwent 1-4 level lumbar fusion for degenerative conditions. OUTCOME MEASURES Daily and total opioid consumption in morphine milligram equivalents (MME). Methods Patients undergoing Results Of 143 OSA patients meeting inclusion criteria, 134 OSA patients were successfully propensity matched to 134 non-OSA patients. Consistent with propensity matching, there was no difference in baseline demographic parameters between cohorts. Patients undergoing OSA had reduced EBL (197mL vs 324mL, p=0.000) and OR time (153min vs 193min, p=0.000) compared to non-OSA. Emergence time (9.9min vs 11.6min, p=0.151) and PACU time (90min vs 88min, p=0.688) was similar between cohorts. There was no difference in LOS (3.3day vs 3.5 days, p=0.599). Daily opioid consumption was reduced from POD 1 (114MME vs 139MME, p=0.002) and maintained each day with decreased total consumption (195MME vs 272MME, p=0.002). Pain score on transfer out of PACU was decreased for OSA patients as well (4.8 vs 6.0, p=0.000). Conclusions In a matched comparison of OSA vs traditional anesthesia for 1-4 lumbar spinal fusions in degenerative conditions we found a reduction in EBL, OR Time, PACU pain scores, and daily/total opioid in hospital consumption. The findings of this pilot study justify ongoing efforts to optimize OSA and undertake larger prospective studies of OSA protocols. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

STUDY DESIGN Retrospective analysis of a prospective registry. OBJECTIVE We utilized the Quality Outcomes Database (QOD) registry to investigate the "July Effect" at QOD spondylolisthesis module sites with residency trainees. SUMMARY OF BACKGROUND DATA There is a paucity of investigation on the long-term outcomes following surgeries involving new trainees utilizing high-quality, prospectively collected data. METHODS This was an analysis of 608 patients who underwent single-segment surgery for grade 1 degenerative lumbar spondylolisthesis at 12 high-enrolling sites. Surgeries were classified as occurring in July or not in July (non-July). Outcomes collected included estimated blood loss, length of stay, operative time, discharge disposition, complications, reoperation and readmission rates, and patient-reported outcomes (Oswestry Disability Index [ODI], Numeric Rating Scale [NRS] Back Pain, NRS Leg Pain, EuroQol-5D [EQ-5D] and the North American Spine Society [NASS] Satisfaction Questionnaire). Propensity score-matched analyses were utilized to compare postoperative outcomes and complication rates between the July and non-July groups. RESULTS Three hundred seventy-one surgeries occurred at centers with a residency training program with 21 (5.7%) taking place in July. In propensity score-matched analyses, July surgeries were associated with longer operative times ( average treatment effect = 22.4 minutes longer, 95% confidence interval 0.9-449.0, P = 0.041). Otherwise, July surgeries were not associated with significantly different outcomes for the remaining perioperative parameters (estimated blood loss, length of stay, discharge disposition, postoperative complications), overall reoperation rates, 3-month readmission rates, and 24-month ODI, NRS back pain, NRS leg pain, EQ-5D, and NASS satisfaction score (P > 0.05, all comparisons). CONCLUSION Although July surgeries were associated with longer operative times, there were no associations with other clinical outcomes compared to non-July surgeries following lumbar spondylolisthesis surgery. These findings may be due to the increased attending supervision and intraoperative education during the beginning of the academic year. There is no evidence that the influx of new trainees in July significantly affects long-term patient-centered outcomes.Level of Evidence: 3.