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Two main surgical approaches are available for fusing the sacroiliac joint (SIJ): an open or minimally invasive (MIS) approach. The purpose of this study was to analyze the associated total hospital charges and postoperative complications of the MIS and open approach. Using the 2016 and 2017 National Readmission Database, we conducted a retrospective cohort analysis of 2521 patients who received a SIJ fusion with an open (N = 1990) or MIS (N = 531) approach for diagnosed sacrum pain, sacroiliitis, sacral instability, or spondylosis. Each cohort was analyzed for postoperative complications. We identified 604 patients diagnosed with sacrum pain, 1142 with sacroiliitis, 315 with spondylosis, and 288 with sacral instability. Patients who received the open approach for sacrum pain had significantly higher rates of novel post-procedural pain (p = 0.045) and novel lumbar pathology (p = 0.015) within 30 days. On 30-day follow-up, patients with sacroiliitis treated with open SIJ fusion had significantly higher rates of novel postprocedural pain compared to those treated with MIS fusion (p = 0.045). Patients who received the open approach for spondylosis resulted in significantly higher rates of non-elective readmission within 30 days compared to the MIS approach (p

Malignant spinal tumors are common, continually increasing in incidence as a function of improved survival times for patients with cancer. Using predictive analytics and propensity score matching, we evaluated the influence of frailty on postoperative complications compared with age in patients with malignant neoplasms of the lumbar spine.We used the Nationwide Readmissions Database from 2016 and 2017 to identify patients with malignant neoplasms of the lumbar spine who received a fusion procedure. Patient frailty was queried using the Johns Hopkins Adjusted Clinical Groups. Propensity score matching for age, sex, Charlson Comorbidity Index, surgical approach, and number of levels fused was implemented between frail and nonfrail patients, identifying 533 frail patients and 538 nonfrail patients. The area under the curve (AUC) of each ROC served as a proxy for model performance.Frail patients reported significantly higher inpatient lengths of stay, costs, infection, posthemorrhagic anemia, and urinary tract infections (P0.05). In addition, frail patients were more often discharged to skilled nursing facilities and short-term hospitals compared with nonfrail patients (P0.0001). Regression models for mortality (AUC = 0.644), nonroutine discharge (AUC = 0.600), and acute infection (AUC = 0.666) were improved when using frailty as the primary predictor. These models were also improved using frailty when predicting 30-day readmission and 90-day hardware failure.Frailty demonstrated a significant relationship with increased postoperative patient complications, length of stay, costs, and acute complications in patients receiving fusion following resection of a malignant neoplasm of the lumbar spine region. Frailty demonstrated better predictive validity of outcomes compared with patient age.

BACKGROUND CONTEXT Outcomes of treatment in care of patients with spinal disorders are directly related to patient selection and treatment indications. However, for many disorders, there is absence of consensus for precise indications. With the increasing emphasis on quality and value in spine care, it is essential that treatment recommendations and decisions are optimized. PURPOSE The purpose of the North American Spine Society Appropriate Use Criteria was to determine the appropriate (ie reasonable) multidisciplinary treatment recommendations for patients with degenerative spondylolisthesis across a spectrum of more common clinical scenarios. STUDY DESIGN A Modified Delphi process was used. METHODS The methodology was based on the Appropriate Use Criteria development process established by the Research AND Development Corporation. The topic of degenerative spondylolisthesis was selected by the committee, key modifiers determined, and consensus reached on standard definitions. A literature search and evidence analysis were completed by one work group simultaneously as scenarios were written, reviewed, and finalized by another work group. A separate multidisciplinary rating group was assembled. Based on the literature, provider experience, and group discussion, each scenario was scored on a nine-point scale on two separate occasions, once without discussion and then a second time following discussion based on the initial responses. The median rating for each scenario was then used to determine if indications were rarely appropriate (1 – 3), uncertain (4-6), or appropriate (7-9). Consensus was not mandatory. RESULTS There were 131 discrete scenarios. These addressed questions on bone grafting, imaging, mechanical instability, radiculopathy with or without neurological deficits, obesity, and yellow flags consisting of psychosocial and medical comorbidities. For most of these, appropriateness was established for physical therapy, injections, and various forms of surgical intervention. The diagnosis of spondylolisthesis should be determined by an upright x-ray. Scenarios pertaining to bone grafting suggested that patients should quit smoking prior to surgery, and that use of BMP should be reserved for patients who had risk factors for non-union. Across all clinical scenarios, physical therapy (PT) had an adjusted mean of 7.66, epidural steroid injections 5.76, and surgery 4.52. Physical therapy was appropriate in most scenarios, and most appropriate in patients with back pain and no neurological deficits. Epidural steroid injections were most appropriate in patients with radiculopathy. Surgery was generally more appropriate for patients with neurological deficits, higher disability scores, and dynamic spondylolisthesis. Mechanical back pain and presence of yellow flags tended to be less appropriate, and obesity in general had relatively little influence on decision making. Decompression alone was more strongly considered in the presence of static versus dynamic spondylolisthesis. On average, posterior fusion with or without interbody fusion was similarly appropriate, and generally more appropriate than stand-alone interbody fusion which was in turn more appropriate than interspinous spacers. CONCLUSIONS Multidisciplinary appropriate treatment criteria were generated based on the Research AND Development methodology. While there were consistent and significant differences between surgeons and non-surgeons, these differences were generally very small. This document provides comprehensive evidence-based recommendations for evaluation and treatment of degenerative spondylolisthesis. The document in its entirety will be found on the North American Spine Society website ( https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria) .

STUDY DESIGN This was a retrospective cohort study. OBJECTIVE The aim of this study was to compare the hospital charges and postoperative complications of minimally invasive surgery (MIS) and open approaches to sacroiliac joint (SIJ) fusion. SUMMARY OF BACKGROUND DATA The data source utilized in this study is the Healthcare Cost and Utilization Project National Readmission Database (NRD) from 2016 and 2017. The NRD is a yearly nationally representative inpatient database from the Agency for Healthcare Research and Quality with information regarding patient demographics, diagnoses, procedures, and readmissions. MATERIALS AND METHODS The 2016-2017 NRD was used to identify 2521 patients receiving SIJ fusion with open (n=1990) or MIS approaches (n=531) for diagnosed sacrum pain, sacroiliitis, sacral instability, or spondylosis after excluding for those who received prior SIJ fusion, those diagnosed with neoplasms or trauma of the pelvis or sacrum, and nonelective procedures. We then one-to-one propensity-matched the open (n=531) to the MIS approach (n=531) for age, sex, and Charlson Comorbidity Index. Statistical analysis was performed to compare total hospital charges, immediate surgical complications, nonelective readmission rate, and 30-, 90-, and 180-day postoperative complications between the 2 approaches. RESULTS The mean total hospital charge was the only significant difference between 2 group. Open SIJ fusion had significantly higher charge compared with the MIS approach (open $101,061.90±$81,136.67; MIS $83,594.78±$49,086.00, P

This study aimed to analyse the trends and patterns of IVD degeneration in different age groups at each level of the thoracic spine. This cross-sectional MRI study included 1000 symptomatic patients who had undergone upright thoracic spine MRI. A total of 13,000 thoracic IVDs from C7/T1 to T12/L1 were classified into five grades using Pfirrmann classification. Patients were divided according to their ages into five groups (n = 200/group). The severity and pattern of IVD degeneration were analysed in each age group. A predictive model of the severity and pattern of IVD degeneration in each age group was proposed. The total grade of IVD degeneration and the number of degenerated levels increased with increasing age (P

Anterior thoracolumbar (TL) surgical approaches provide more direct trajectories compared to posterior approaches. Proper patient selection is key in identifying populations that may benefit from anterior TL fusion. Here, we utilize predictive analytics to identify risk factors in anterior TL fusion in patients with trauma and deformity. In this retrospective cohort study of patients receiving anterior TL fusion (between and including T12/L1), population-based regression models were developed to identify risk factors using the National Readmission Database 2016–2017. Readmissions were analyzed at 30- and 90-day intervals. Risk factors included hypertension, obesity, malnutrition, smoking, alcohol use, long-term opioid use, and frailty. Multivariate regression models were developed to determine the influence of each risk factor on complication rates. A total of 265 and 375 patients were identified for the scoliosis and burst fracture cohorts, respectively. In patients with scoliosis, alcohol use was found to increase the length of stay (LOS) (p = 0.00061) and all-payer inpatient cost following surgery (p = 0.014), and frailty was found to increase the inpatient LOS (p = 0.0045). In patients with burst fractures, malnutrition was found to increase the LOS (p

Study Design: Retrospective comparative study. Objectives: To compare the perioperative complications of propensity score-matched cohorts of patients with degenerative cervical myelopathy (DCM), who were treated with anterior cervical discectomy and fusion (ACDF), posterior laminectomy with fusion, or laminoplasty. Methods: The Humana PearlDiver Patient Record Database was queried using the International Classification of Diseases (ICD-9 and ICD-10) and the Current Procedural Terminology (CPT) codes. Propensity score-matched analysis was done using multiple Chi-squared tests with Bonferroni correction of the significance level. Results: Cohorts of 11,790 patients who had ACDF, 2,257 patients who had posterior laminectomy with fusion, and 477 patients who had laminoplasty, were identified. After propensity score matching, all the 3 groups included 464 patients. The incidence of dysphagia increased significantly following ACDF compared to laminoplasty, P < 0.001, and in laminectomy with fusion compared to laminoplasty, P < 0.001. The incidence of new-onset cervicalgia was higher in ACDF compared to laminoplasty, P = 0.005, and in laminectomy with fusion compared to laminoplasty, P = 0.004. The incidence of limb paralysis increased significantly in laminectomy with fusion compared to ACDF, P = 0.002. The revision rate at 1 year increased significantly in laminectomy with fusion compared to laminoplasty, P < 0.001, and in ACDF compared to laminoplasty, P < 0.001. Conclusions: The incidence of dysphagia following laminectomy with fusion was not different compared to ACDF. Postoperative new-onset cervicalgia and revisions were least common in laminoplasty. The highest rate of postoperative limb paralysis was noticed in laminectomy with fusion.

This study was a retrospective cohort database study which looked at the relationship between myocardial reinfarction following lumbar spine surgery.Current study aimed to determine the risk of reinfarction associated with the time between initial myocardial infarction (MI) and lumbar spine surgery, type of lumbar surgical procedure, and other risk factors.Several studies have demonstrated a strong temporal pattern between postoperative reinfarction rate and the period between previous MI and surgery. To the best of our knowledge, no study has looked specifically at the temporal relationship between previous MI, lumbar spine surgery and incidence of postoperative myocardial reinfarction.The Humana database was analyzed from Q1 2007 through Q3 2016 and the Medicare database was analyzed from Q1 2005 through Q4 2014. Patients were placed into 1 of 5 groups based on time between MI and surgery: 0-3, 4-6, 7-12, 13-24, and 25+ months. Reinfarction rates were determined in these groups. Age, sex, and type of surgery were analyzed to determine association with postoperative reinfarction rates.There was a strong correlation between postoperative myocardial reinfarction and lumbar spine surgery occurring 0-3 months after the patient's initial MI (P0.01). Those patients had a risk ratio3 (P0.01) compared with patients who underwent lumbar spine surgery after an interval3 months between initial MI and lumbar spine surgery. In addition, spinal fusion procedures were associated with a greater risk of postoperative myocardial reinfarction than nonfusion procedures.In both databases, there was a clinically relevant and statistically significant increase in myocardial reinfarction in patients who experienced an MI 0-3 months before lumbar spine surgery. We believe that the current study helps in treatment planning for patients with a history of MI who are considering spine surgery.Level III.

To elucidate the effects of bisphosphonates on complications following posterior lumbar fusion (PLF) with a large database study. The PearlDiver Patient Record Database was queried to identify adult patients who had undergone posterior lumbar fusion (PLF). Those patient cohorts were divided based on a diagnosis of osteoporosis prior to surgery and bisphosphonate usage. This yielded three groups: Osteo+Bisph+, Osteo+Bisph−, and Osteo−Bisph−. The primary outcome of the present study was revision rates at 6 months and 1 year following surgery. Incidence of postoperative complications was analyzed, and statistical analysis was conducted using Pearson chi-square analysis. Patients taking bisphosphonates did not have significantly different rates of revision surgery at 6 months and 1 year, instrumentation complications, or post-vertebral fractures than patients not taking bisphosphonates. Additionally, osteoporotic patients did not have significantly different rates of these complications than patients without osteoporosis. Bisphosphonate usage did not significantly affect the rates of postoperative complications following posterior lumbar fusion. Further research is required to fully elucidate the effects of bisphosphonates on outcomes and complications following spine surgery.

Study design Systematic review. Objective To characterize the effects of postoperative physical therapy (PT) after surgery for cervical spondylosis on patient-reported outcomes and impairments. Secondarily, to identify associated complications, adverse effects, and health care costs with postoperative PT, and to describe the content, timing, and duration of the PT. Summary of background data Cervical spine surgery is common; however, it is unclear if the addition of postoperative PT leads to improved patient outcomes and decreased health care costs. Materials and methods PubMed, Embase, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database, and Web of Science were searched until July 2019. All peer-reviewed articles involving cervical spine surgery with postoperative PT for cervical spondylosis were considered for inclusion. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials. Findings were described narratively, and GRADE approach was used to define the quality of evidence. Results A total of 10,743 studies were screened. Six studies met inclusion criteria; 2 randomized controlled trials and 4 subsequent follow-up studies containing study arms that included postoperative PT after cervical spine surgery. Meta-analysis was not performed due to study heterogeneity and no study compared PT+surgery to surgery alone. PT treatment included exercise therapy, cognitive behavioral therapy, and optional vestibular rehabilitation. Included studies indicated PT appeared to have positive effects on patient outcomes, however, there were no treatment control groups and the quality of evidence was very low to low. Timing, duration, and content of PT programs varied. No studies reported complications, adverse effects, or cost-effectiveness relating to PT after surgery. Conclusions Current literature prevents a definitive conclusion regarding the impact of postoperative PT, given the lack of treatment control groups. PT treatment was limited to exercise therapy, cognitive behavioral therapy, and optional vestibular rehabilitation in the included studies. PT treatment varied, limiting consistent recommendations for content, timing, and treatment duration. Controlled trials are needed to determine the effectiveness of the addition of postoperative PT following cervical spine surgery for cervical spondylosis. Level of evidence Level II.

Study Design: Retrospective review of insurance database.Purpose: To investigate national trends, complications, and costs after cervical disc replacement (CDR) using an administrative insurance database representative of the United States population.Overview of Literature: As CDR continues to be used to treat patients with cervical stenosis, it is important to gain a better understanding of its use on a national level, potential complications, and cost. This information will allow for optimal patient counseling, risk stratification, and healthcare cost assessments. Several prior studies have investigated complications associated with CDR, but they have been limited by small sample size, single institution experiences, limited follow-up, and potential conflicts of interest.Methods: Patients who underwent single or multilevel CDR between 2007 and 2015 were identified using an insurance database. We collected data on annual trends, reimbursement costs, patient demographic information, hospital information, and information on complications from the time of operation to 1 year postoperative.Results: Total of 293 patients underwent either single or multilevel CDR. The number of procedures increased nonlinearly over time at an average of 17% per year, with a greater increase seen in the outpatient setting. Less than 3.7% of patients had new onset pain within 1 year after CDR. Within 1 year, 12.3% of patients reported a mechanical and/or bone-related complication. There were no patients who indicated a new nerve injury within 6 months of follow-up. Less than 3.7% of patients presented with dysphagia or dysphonia within 6 months, infection within 3 months, or a revision or reoperation within 1 year. Average reimbursement for single-level inpatient versus outpatient CDR was US $33,696.28 and US $34,675.12, respectively (p =0.29).Conclusions: This study demonstrated that the use of CDR continued to increase. The most common complication was mechanical and/or bone-related, and cost analysis demonstrated no significant difference between inpatient and outpatient CDR.

Study Design: Review. Objective: Venothromboembolic (VTE) complications, composed of deep vein thrombosis and pulmonary embolism are commonly observed in the perioperative setting. There are approximately 500 000 postoperative VTE cases annually in the United States and orthopedic procedures contribute significantly to this incidence. Data on the use of VTE prophylaxis in elective spinal surgery is sparse. This review aims to provide an updated consensus within the literature defining the risk factors, diagnosis, and the safety profile of routine use of pharmacological prophylaxis for VTE in elective spine surgery patients. Methods: A comprehensive review of the literature and compilation of findings relating to current identified risk factors for VTE, diagnostic methods, and prophylactic intervention and safety in elective spine surgery. Results: VTE prophylaxis use is still widely contested in elective spine surgery patients. The outlined benefits of mechanical prophylaxis compared with chemical prophylaxis varies among practitioners. Conclusion: The benefits of any form of VTE prophylaxis continues to remain a controversial topic in the elective spine surgery setting. A specific set of guidelines for implementing prophylaxis is yet to be determined. As more risk factors for thromboembolic events are identified, the complexity surrounding intervention selection increases. The benefits of prophylaxis must also continue to be balanced against the increased risk of bleeding events and neurologic injury.

Study Design: Cross-sectional, international survey. Objectives: To identify factors influencing pharmacologic anticoagulation initiation after spine surgery based on the AOSpine Anticoagulation Global Survey. Methods: This survey was distributed to the international membership of AOSpine (n = 3805). A Likert-type scale described grade practice-specific factors on a scale from low (1) to high (5) importance, and patient-specific factors a scale from low (0) to high (3) importance. Analysis was performed to determine which factors were significant in the decision making surrounding the initiation of pharmacologic anticoagulation. Results: A total of 316 spine surgeons from 64 countries completed the survey. In terms of practice-specific factors considered to initiate treatment, expert opinion was graded the highest (mean grade ± SD = 3.2 ± 1.3), followed by fellowship training (3.2 ± 1.3). Conversely, previous studies (2.7 ± 1.2) and unspecified guidelines were considered least important (2.6 ± 1.6). Patient body mass index (2.0 ± 1.0) and postoperative mobilization (2.3 ± 1.0) were deemed most important and graded highly overall. Those who rated estimated blood loss with greater importance in anticoagulation initiation decision making were more likely to administer thromboprophylaxis at later times (hazard ratio [HR] = 0.68-0.71), while those who rated drain output with greater importance were likely to administer thromboprophylaxis at earlier times (HR = 1.32-1.43). Conclusion: Among our global cohort of spine surgeons, certain patient factors (ie, patient mobilization and body mass index) and practice-specific factors (ie, expert opinion and fellowship training) were considered to be most important when considering anticoagulation start times.

Introduction Recent literature has associated pseudarthrosis and pedicle screw loosening with subchronic infection at the pedicle of the vertebra. The positive culture results of a previous retrieval analysis show that such patients have a high frequency of bacterial contamination. The objective of this study is to visually capture the architecture of these undiagnosed infections, which have been described in other studies as biofilms on supposedly "aseptic" screw loosening. Methods Explants from 10 consecutive patients undergoing revision spine surgery for pseudarthrosis were collected and fixed in glutaraldehyde solution. Each of these implants was imaged thoroughly by using scanning electron microscopy and x-ray spectroscopy to evaluate the architecture of the biofilm. Additionally, eight patient swabs from tissues around the implants were sent for cultures to assess bacterial infiltration in tissues beyond the biofilm. The implants were also analyzed using energy dispersive x-ray spectroscopy. The exclusion criteria included clinically diagnosed infection (current or previous) and/or mechanical failure of the implant due to falls/accidents. Results The study was successful in capturing the visual architecture of the biofilm on retrieved implants. A total of 77% of pseudarthrosis cases presented with loose pedicle screws, which were diagnosed by a preoperative computed tomography scan showing radiolucency along the screw track and were confirmed intraoperatively, and 72% of the cases showed biofilm on explants. Conclusions In the absence of the clinical presentation of infection, impregnated bacteria could form a biofilm around an implant, and this biofilm can remain undetected via contemporary diagnostic methods, including swabbing. Implant biofilm is frequently present in "aseptic" pseudarthrosis cases.

Background Lymphocele is a rare complication following anterior lumbar interbody fusion with very few reported cases in the literature. We report 3 cases of lymphocele following anterior lumbar interbody fusion. Case Description In the first 2 cases, the patients presented with retroperitoneal lymphocele, and both were managed with sclerotherapy with ethanol. In the third case, the patient also presented with a retroperitoneal lymphocele and was managed instead with percutaneous drain placement. All 3 patients had subsequent resolution of the lymphoceles and their associated symptoms. Conclusions This case report reviews the diagnostic algorithm and management of lymphocele following anterior lumbar interbody fusion.

STUDY DESIGN Retrospective database study. OBJECTIVE To assess the intra- and postoperative complications of cervical laminoplasty and to evaluate the effect of intraoperative neuromonitoring use on postoperative limb paralysis incidence. SUMMARY OF BACKGROUND DATA Cervical laminoplasty is a known procedure for the management of cervical spondylotic myelopathy (CSM). METHODS This was a retrospective study of 532 patients with CSM who underwent cervical laminoplasty between 2007 and the first quarter of 2016 using the Humana subset of the PearlDiver Database. The database was queried using the relevant International Classification of Diseases (ICD-9 and ICD-10) codes for CSM and Current Procedural Terminology (CPT) codes for cervical laminoplasty. The intra- and postoperative incidence of surgical and medical complications and reoperations was then determined and was compared with a propensity score-matched cohort of patients who had posterior laminectomy and fusion (490 patients in each group), using multivariate logistic regression analysis. RESULTS Laminoplasty was associated with a lower incidence of dysphagia (odds ratio [OR] = 0.37, 95% confidence interval [CI] = 0.16-0.79; P = 0.014), 30-day readmission (OR = 0.51, 95% CI = 0.35-0.75; P

To evaluate the reliability and validity of the multi-positional magnetic resonance imaging in measuring occipitocervical parameters using the standard cervical dynamic radiographs as a reference. Patients were included if they underwent both dynamic radiograph and cervical multi-positional MRI within a 2-week interval from January 2013 to December 2016. Twelve occipitocervical parameters were measured on both image modalities in all positions (neutral, flexion and extension): Posterior Atlanto-Dental Interval, Anterior Atlanto-Dental Interval (AADI), Dens-to-McRae distance, Dens-to-McGregor distance, Occipito-atlantal Cobb angle (C01 angle), Occipito-axis Cobb angle (C02 Cobb angle), Atlas-axis Cobb angle (C12 angle), Redlund-Johnell, Modified Ranawat, Clivus canal angle, Occiput inclination, and Occiput cervical distance. Pearson correlation and linear regression analysis were used to evaluate the correlation of both modalities for each parameter. A p value of 0.4) for Modified Ranawat, Clivus canal angle, C02 Cobb angle and C02 distance in all neck position. The intra-class correlation (ICC) of intra- and inter-observer showed good to excellent reliability, and ICCs were 0.67–0.98. Multi-positional MRI can be a reliable imaging option for diagnosis of occipitocervical instability or basilar invagination compared to standard dynamic radiographs.

Study Design: Retrospective database. Objectives: Although posterior decompression is the most common approach for surgical treatment of degenerative thoracic spine disease, anterior approach is gaining interest due to its advantage in disc visualization. The objective of this study was to compare the intra- and postoperative medical complication rates between anterior and posterior decompression for degenerative thoracic spine pathologies. Methods: A national US insurance database was queried for patients with degenerative diagnoses who had undergone anterior or posterior thoracic decompression. Incidence of intra- and postoperative complications were evaluated on the day of surgery and within 1 and 3 months. Two subgroups were matched based on age, gender, and comorbidity. The association of decompression approach and complications was assessed using logistic regression. Results: A total of 1459 patients were included, consisting of 1004 patients in posterior and 455 patients in anterior group. Respiratory complications were the most common complications on the day of surgery (8.57%) and within 30 days (17.75%). Matched analysis showed that anterior approach was associated with organ failure, gastrointestinal, and device-/implant-/graft-related complications in all follow-up periods; and with cardiovascular, deep venous thrombosis/pulmonary embolism, and respiratory complications in at least 1 follow-up period. Among respiratory complications, anterior decompression was significantly associated with noninfectious etiologies on the day of surgery (odds ratio [OR] = 1.72), within 30 days (OR = 2.05), and within 90 days (OR = 1.92). Conclusions: Anterior approach was associated with increased rates of several complications. High rates of respiratory complications necessitate comprehensive preoperative risk stratification to identify those who may benefit more from posterior approach.

Purpose: This study evaluates the influence of patient frailty status on postoperative complications in those receiving single-level lumbar fusion surgery. Methods: The nationwide readmission database was retrospectively queried between 2016 and 2017 for all patients receiving single-level lumbar fusion surgery. Readmissions were analyzed at 30, 90, and 180 days from primary discharge. Demographics, frailty status, and relevant complications were queried at index admission and all readmission intervals. Complications of interest included infection, urinary tract infection (UTI), posthemorrhagic anemia, inpatient length of stay (LOS), and adjusted all-payer costs. Nearest-neighbor propensity score matching for demographics was implemented to identify non-frail control patients with similar diagnoses and procedures. The analysis used nonparametric Mann–Whitney U testing and odds ratios. Results: Comparing propensity-matched cohorts revealed significantly greater LOS and total all-payer inpatient costs in frail patients than non-frail patients with comparable demographics and comorbidities (p

BACKGROUND CONTEXT The concept of frailty has become increasingly recognized, and while patients with cancer are at increased risk for frailty, its influence on perioperative outcomes in metastatic spine tumors is uncertain. Furthermore, the impact of frailty can be confounded by comorbidities or metastatic disease burden. PURPOSE The purpose of this study was to evaluate the influence of frailty and comorbidities on adverse outcomes in the surgical management of metastatic spine disease. STUDY DESIGN/SETTING Retrospective Cohort Study. PATIENT SAMPLE A total of 7,772 patients underwent spinal fusion with spinal metastasis within the Nationwide Readmissions Database (NRD). OUTCOME MEASURES Mortality, medical complications, surgical complications, increased length of stay (LOS), nonroutine discharge and increased costs. METHODS A validated binary frailty index (Johns Hopkins Adjusted Clinical Groups) was used to identify frail and non-frail groups, and propensity score-matched analysis (including demographics, comorbidities, surgical and tumor characteristics) was performed. Sub- group analysis of levels involved was performed for cervical, thoracic, lumbar and junctional spine. Outcomes analyzed included mortality, complications, length of stay (LOS), nonroutine discharges and costs. Multivariable-regression techniques were used to develop predictive models for outcomes using frailty and the Elixhauser Comorbidity Index (ECI). RESULTS A total of 7,772 patients underwent spinal fusion with spinal metastasis, of which 1,974 (25.4%) patients were identified as frail. Following propensity score matching for frail (n= 1,974) and not-frail (n=1,975) groups, frailty demonstrated significantly greater medical complications (OR=1.58; 95% CI 1.33-1.86), surgical complications (OR=1.46; 95% CI 1.15-1.85), LOS (OR=2.65; 95% CI 2.09-3.37), nonroutine discharges (OR=1.79; 95% CI 1.46-2.20) and costs (OR=1.68; 95% CI 1.32-2.14). Differences in mortality were only observed in subgroup analysis and were greater in frail junctional and lumbar spine subgroups. Models using ECI alone (AUC= 0.636-0.788) demonstrated greater predictive ability compared to those using frailty alone (AUC=0.633-0.752). However, frailty combined with ECI improved the prediction of increased LOS (AUC=0.811), cost (AUC=0.768), medical complications (AUC=0.723) and nonroutine discharges (AUC=0.718). Predictive modeling of frailty in subgroups demonstrated the greatest performance for mortality (AUC=0.750) in the lumbar spine, otherwise performed similarly for LOS, costs, complications, and discharge across subgroups. CONCLUSIONS A high prevalence of frailty existed in the current patient cohort. Frailty contributed to worse short-term adverse outcomes and could be more influential in the lumbar and junctional spine due to higher risk of deconditioning in the postoperative period. Predictions for short-term outcomes can be improved by adding frailty to comorbidity indices, suggesting a more comprehensive preoperative risk stratification should include frailty. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

As the population continues to age, the number of lumbar spine surgeries continues to increase. While there are many complications associated with lumbar surgeries, a myocardial infarction (MI) is a particularly devastating one. This complication is of considerable importance with mortality rates of postoperative MI documented between 26.5 and 70%. This study aimed to determine the relationship between lumbar surgeries, preoperative diagnoses (risk factors), and myocardial infarction.Data from the Humana database (PearlDiver) were analyzed from 2007 to 2016. Patients undergoing lumbar spine surgeries were identified and stratified based on procedural approach, patient demographics, and preoperative risk factors. Each group was analyzed to determine the incidence and relative risk. Chi-square analysis was used to determine the significance.A total of 105,505 patients who fit inclusion criteria were identified in the PearlDiver database between 2007 and 2016. A total of 644 patients (0.63%) experienced a postoperative myocardial infarction within 30 days of surgery. Patients undergoing fusion and non-fusion procedures showed significantly different rates of postoperative myocardial infarction (0.08% vs. 0.05%, p 0.01). Male patients, older patients, and patients with a Charlson comorbidity index 3 showed a considerable increase in incidence (p 0.01). Furthermore, patients with preoperative risk factors (high cholesterol, obesity, depression, congestive heart failure, hypertension, and hypotension) exhibited risk ratios from 0.01 to 1.85 (p 0.01).Preoperative risk factors, patient demographics, and procedure type had a significant effect on the incidence of postoperative myocardial infarction. These slides can be retrieved under Electronic Supplementary Material.

Objective To compare the rates of deep venous thrombosis (DVT), rates of pulmonary embolus (PE), and complication profiles of warfarin and low-molecular-weight heparin (LMWH) in patients undergoing operative fixation of hip fractures. Design Retrospective cohort study. Setting Insurance-based database of more than 22 million patient records. Patients Adult hip fracture patients who were treated operatively and received chemoprophylaxis from 2007 to 2016. A total of 7594 patients met inclusion criteria and were available for final analysis. Intervention Pharmacological anticoagulation with warfarin or LMWH to prevent postoperative venous thromboembolism after hip fracture surgery. Main outcome measures Development of DVT or PE within 30 and 90 days of surgery. Results Patients prescribed warfarin had higher rates of DVT and PE compared with those prescribed LMWH. Patients on warfarin were more likely to develop a postoperative hematoma and to be readmitted within 30 and 90 days compared with those on LMWH. Patients in both groups had similar rates of total complications. Conclusions Patients prescribed warfarin after hip fractures had higher rates of DVT and PE compared with those prescribed LMWH, although both agents had similar complication profiles. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

This is a retrospective cohort study.This study's objective was to determine whether perioperative invasive vascular catheter placement, independent of comorbid conditions, modified the risk of postoperative infection in lumbar spine surgery.Infection is a risk inherent to lumbar spine surgery, with overall postoperative infection rates of 0.86%-8.5%. Patients experiencing postoperative infection have higher rates of mortality, revision surgeries, pseudarthrosis, and worsening pain and disability.Data were collected for patients undergoing lumbar spine surgery between January 2007 and October 2015 with records in the nationwide Humana private insurance database. Patients receiving fusion, laminectomy, and discectomy were followed for 3 months from the date of surgery for surgical site infection (SSI), 6 months for subsequent incision and drainage (ID), and 1 year for vertebral osteomyelitis (VO). Risk factors investigated included central venous catheter and arterial-line placement.Analysis of 114,259 patient records showed an overall SSI rate of 3.2% within 1 month and 4.5% within 3 months, overall vertebral osteomyelitis rate of 0.82%-0.83% within 1 year, and overall ID rate of 2.8% within 6 months. Patients receiving a first-time invasive vascular catheter on the day of surgery were more likely to experience SSI within 1 month [risk ratios (RR), 2.5, 95% confidence interval (CI): 2.3-2.7], SSI within 3 months (RR, 2.4; 95% CI: 2.3-2.7), osteomyelitis within 1 year (RR, 4.2-4.3; 95% CI: 3.7-4.5), and undergo an ID within 6 months (RR, 1.9; 95% CI: 1.8-2.0). These trends were consistent by procedure type and independent of the patient's weighted comorbidity index score (Charlson Comorbidity Index).Perioperative invasive vascular catheterization was significantly associated with an increased the risk of postoperative infections in lumbar spine surgery, independent of a patient's concomitant comorbidities. Therefore, in patients with an indication for invasive catheterization, surgeons should consider risks and benefits of surgery carefully.Level III.

The correlation between BMP-2 and osteosarcoma growth has gained increased interest in the recent years, however, there is still no consensus. In this study, we tested the effects of BMP-2 on osteosarcoma cells through both in vitro and in vivo experiments. The effect of BMP-2 on the proliferation, migration and invasion of osteosarcoma cells was tested in vitro. Subcutaneous and intratibial tumor models were used for the in vivo experiments in nude mice. The effects of BMP-2 on EMT of osteosarcoma cells and the Wnt/β-catenin signaling pathway were also tested using a variety of biochemical methods. In vitro tests did not show a significant effect of BMP-2 on tumor cell proliferation. However, BMP-2 increased the mobility of tumor cells and the invasion assay demonstrated that BMP-2 promoted invasion of osteosarcoma cells in vitro. In vivo animal study showed that BMP-2 dramatically enhanced tumor growth. We also found that BMP-2 induced EMT of osteosarcoma cells. The expression levels of Axin2 and Dkk-1 were both down regulated by BMP-2 treatment, while β-catenin, c-myc and Cyclin-D1 were all upregulated. The expression of Wnt3α and p-GSK-3β were also significantly upregulated indicating that the Wnt/β-catenin signaling pathway was activated during the EMT of osteosarcoma driven by BMP-2. From this study, we can conclude that BMP-2 significantly promotes growth of osteosarcoma cells (143B, MG63), and enhances mobility and invasiveness of tumor cells as demonstrated in vitro. The underlying mechanism might be that BMP-2 promotes EMT of osteosarcoma through the Wnt/β-catenin signaling pathway. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1638-1648, 2019.

INTRODUCTION With healthcare expenditure in the national forefront, outpatient arthroplasty is an appealing option in select patient populations. The purpose of this study was to determine the complication rates associated with outpatient total hip arthroplasty (THA) in comparison to standard inpatient THA. METHODS We performed a retrospective review of the Humana subset of the PearlDiver insurance records database to identify patients undergoing THA (Current Procedural Terminology-27130 and Current Procedural Terminology-27132) as either outpatients or inpatients from 2007 to 2016. Multivariate logistic regression adjusting for age, gender, and Charlson Comorbidity Index were used to calculate odds ratios of complications among outpatients undergoing THA relative to inpatients undergoing THA. RESULTS The query identified 2,184 patients who underwent outpatient THA and 73,596 patients who underwent inpatient THA. The median age was in the 65 to 69 age group and in the 70 to 74 age group for the outpatient and inpatient cohorts, respectively (P < 0.001). Outpatients undergoing THA had a significantly lower incidence of comorbid hypertension (P < 0.001), cerebrovascular disease (P = 0.001), obesity (P = 0.017), chronic obstructive pulmonary disorder (P = 0.045), and chronic kidney disease (P = 0.049). The incidence of both outpatient THA (P = 0.001) and inpatient THA (P < 0.001) increased over the study period. After adjusting for age, gender, and Charlson Comorbidity Index, patients undergoing outpatient THA had comparable rates of all queried surgical complications, including component revision, irrigation and debridement, and hip dislocation at 1 year. Rates of postoperative medical complications were also comparable between the two cohorts. CONCLUSION Outpatient THA is increasing in frequency nationwide and has comparable postoperative complication rates. With its potential to minimize arthroplasty care costs, outpatient THA is a safe and effective option among appropriately selected patients.

STUDY DESIGN Retrospective cohort study using the 2013-2017 National Readmission Database. OBJECTIVE The aim of this study was to quantify the influence of body mass index (BMI) on complication and readmission rates following lumbar spine fusion. SUMMARY OF BACKGROUND DATA Compared to controls, patients with BMI ≥35 had greater odds of readmission, infection, and wound complications following lumbar spine fusion. METHODS Patients who underwent elective lumbar spine fusion within the population-based sample were considered for inclusion. Exclusion criteria included nonelective lumbar spine fusions, malnourished, anorexic, or underweight patients, and surgical indications of trauma or neoplasm. Patients were grouped by BMI: 18.5 to 29.9 (controls), 30 to 34.9 (obesity I), 35 to 39.9 (obesity II), and ≥40 (obesity III). Multivariate regression was performed to analyze differences in complications and readmissions between groups. Predictive modeling was conducted to estimate the impact of BMI on 30- and 90-day infection, wound complication, and readmissions rates. RESULTS A total of 86,697 patients were included for analysis, with an average age of 58.9 years and 58.9% being female. The obesity II group had significantly higher odds of infection (odds ratio [OR]: 1.82, 95% confidence interval [CI]: 1.28-2.62, P = 0.001), wound dehiscence (OR: 3.08, 95% CI: 1.70-6.18, P = 0.0006), and 30-day readmission (OR: 1.32, 95% CI: 1.11-1.58, P = 0.002), whereas the obesity III group had significantly higher odds of acute renal failure (OR: 2.14, 95% CI: 1.20-4.06, P = 0.014), infection (OR: 2.43, 95% CI: 1.72-3.48, P

STUDY DESIGN This is a retrospective cohort study of consecutive patients undergoing lumbar spinal fusion (LSF) within the PearlDiver Humana research database from 2010 to 2018. OBJECTIVE The aim of this study was to determine if timing of total hip arthroplasty (THA) affects LSF outcomes. SUMMARY OF BACKGROUND DATA In patients with both spine and hip pathology, outcomes of THA have been shown to be affected by the timing of THA relative to LSF. However, few studies have assessed postoperative outcomes following LSF in this clinical scenario. MATERIALS AND METHODS A national database was queried for patients undergoing lumbar fusion and divided into 4 groups: (1) those who underwent LSF without THA (No THA); (2) those who underwent THA at least 2 years before LSF (>2 Prior THA); (3) those who underwent THA in the 2 years before LSF (0-2 Prior THA); and (4) those who underwent THA after LSF (THA After). We assessed lumbar-specific outcomes, including pseudarthrosis, revision, mechanical failure, and adjacent segment disease (ASD); as well as systemic complications. Controlling for age, sex, and Charlson comorbidity index, complication rates between all groups were assessed using univariate and multivariate logistic regression analysis. Post hoc comparisons were performed using the Fisher exact test with Bonferroni correction to account for multiple pairwise comparisons, resulting in an adjusted threshold for statistical significance of P

High quality evidence is difficult to generate, leaving substantial knowledge gaps in the treatment of spinal conditions. Appropriate use criteria (AUC) are a means of determining appropriate recommendations when high quality evidence is lacking.Define appropriate use criteria (AUC) of cervical fusion for treatment of degenerative conditions of the cervical spine.Appropriate use criteria for cervical fusion were developed using the RAND/UCLA appropriateness methodology. Following development of clinical guidelines and scenario writing, a one-day workshop was held with a multidisciplinary group of 14 raters, all considered thought leaders in their respective fields, to determine final ratings for cervical fusion appropriateness for various clinical situations.Final rating for cervical fusion recommendation as either "Appropriate," "Uncertain" or "Rarely Appropriate" based on the median final rating among the raters.Inclusion criteria for scenarios included patients aged 18 to 80 with degenerative conditions of the cervical spine. Key modifiers were defined and combined to develop a matrix of clinical scenarios. The median score among the raters was used to determine the final rating for each scenario. The final rating was compared between modifier levels. Spearman's rank correlation between each modifier and the final rating was determined. A multivariable ordinal regression model was fit to determine the adjusted odds of an "Appropriate" final rating while adjusting for radiographic diagnosis, number of levels and symptom type. Three decision trees were developed using decision tree classification models and variable importance for each tree was computed.Of the 263 scenarios, 47 (17.9 %) were rated as rarely appropriate, 66 (25%) as uncertain and 150 (57%) were rated as appropriate. Symptom type was the modifier most strongly correlated with the final rating (adjusted ρ2 = 0.58, p.01). A multivariable ordinal regression adjusting for symptom type, diagnosis, and number of levels and showed high discriminative ability (C statistic = 0.90) and the adjusted odds ratio (aOR) of receiving a final rating of "Appropriate" was highest for myelopathy (aOR, 7.1) and radiculopathy (aOR, 4.8). Three decision tree models showed that symptom type and radiographic diagnosis had the highest variable importance.Appropriate use criteria for cervical fusion in the setting of cervical degenerative disorders were developed. Symptom type was most strongly correlated with final rating. Myelopathy or radiculopathy were most strongly associated with an "Appropriate" rating, while axial pain without stenosis was most associated with "Rarely Appropriate."

STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of this study was to compare different aspects of fusion surgery in patients with osteoporosis with regard to graft subtype and surgical approach. SUMMARY OF BACKGROUND DATA Osteoporosis and chronic lower back pain are common in elderly populations and significantly increase the risk of compression fractures within the spine. METHODS Using the 2016-2017 National Readmission Database we identified 11,086 osteoporotic patients who received lumbar fusion using ICD-10 coding. Information regarding biologic graft type and surgical approach was collected. Patients were stratified by number of levels fused. Perioperative complications were collected at 30-, 90-, and 180-day follow-up intervals. Statistical analysis included univariate testing and multivariate regression modeling, controlling for patient demographics and comorbidities. RESULTS Patients receiving single-level fusion with autologous grafts had higher rates of hardware failure (P = 0.00014) at 30-day follow-up and 90-day follow-up (P

Background Modifiable risk factors (MRFs) represent patient variables associated with increased complication rates that may be prevented. There exists a paucity of studies that comprehensively analyze MRF subgroups and their independent association with postoperative complications in patients undergoing cervical spine surgery. Therefore, the purpose of this study is to compare outcomes between patients receiving cervical spine surgery with reported MRFs. Methods Retrospective analysis of the Nationwide Readmissions Database (NRD) from the years 2016 and 2017, a publicly available and purchasable data source, to include adult patients undergoing cervical fusion. MRF cohorts were separated into three categories: substance abuse (alcohol, tobacco/nicotine, opioid abuse); vascular disease (hypertension, dyslipidemia); and dietary factors (malnutrition, obesity). Three-way nearest-neighbor propensity score matching for demographics, hospital, and surgical characteristics was implemented. Findings We identified 9601 with dietary MRFs (D-MRF), 9654 with substance abuse MRFs (SA-MRF), and 9503 with vascular MRFs (V-MRF). Those with d-MRFs had significantly higher rates of medical complications (9.3%), surgical complications (8.1%), and higher adjusted hospital costs compared to patients with SA-MRFs and V-MRFs. Patients with d-MRFs (16.3%) and V-MRFs (14.0%) were independently non-routinely discharged at a significantly higher rate compared to patients with SA-MRFs (12.6%) (p

Study Design: Retrospective cross-sectional study. Objectives: To determine if pre-operative albumin and CRP can predict post-operative infections after lumbar surgery. Methods: Patients who underwent an anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF), or lumbar discectomy were identified using a patient record database (PearlDiver) and were included in this retrospective study. Patients were stratified by Charlson Comorbidity Index (CCI) scores and pre-operative albumin and CRP status. Post-operative complications included deep infections and urinary tract infections within 3 months of the surgery and revisions within 1 year of the surgery. Results: 74,280 patients were included in this study. 21,903 had pre-operative albumin or CRP lab values. 7,191 (33%), 12,183 (56%), and 2,529 (12%) patients underwent an ALIF, PLIF, and a lumbar discectomy, respectively. 16,191 did not have any complication (74%). The most common complication was UTI (16%). Among all patients, hypoalbuminemia was a significant risk factor for deep infection and UTI after ALIF, deep infection, UTI, and surgical revision after PLIF, and deep infection after lumbar discectomy. Elevated CRP was a significant risk factor for deep infection after ALIF, UTI after PLIF, and deep infection after lumbar discectomy in patients with a CCI ≤ 3. Conclusions: Pre-operative hypoalbuminemia and elevated CRP were significant risk factors for deep infection, UTI, and/or revision, after ALIF, PLIT, and/or lumbar discectomy. Future studies with a larger population of patients with low albumin and high CRP values are needed to further elaborate on the current findings.

BACKGROUND CONTEXT Lumbar fusions are commonly used surgical techniques for the treatment of instability and degenerative disc disease. Few studies have examined if the non-opioid analgesics Gabapentin and Pregabalin can effectively manage postoperative pain following common lumbar fusion procedures. PURPOSE This study aims to examine postoperative complications associated with the use of non-opioid analgesics (ie, Gabapentin or Pregabalin) for postoperative pain management following anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF), or transforaminal lumbar interbody fusion (TLIF). STUDY DESIGN/SETTING Retrospective database review. PATIENT SAMPLE Patient cohort identified using MSpine national database that includes patients of all payer types who received fusion procedures. OUTCOME MEASURES Complications examined included the following: neurologic, GI, respiratory, DVT and pulmonary embolism, pruritus, mental disorders, urinary incontinence and postoperative pain. METHODS The MSpine national database was queried with relevant Current Procedural Terminology (CPT) codes for patients who underwent an ALIF, PLIF, or TLIF between 2010 to 2019. Patients were organized into anterior approach and posterior approach groups and further queried using National Drug Codes (NDC) to form cohorts of patients who received (i) exclusively opioids, or (ii) a mix regimen, for postoperative pain management. A search of relevant International Classification of Diseases (ICD-9 and ICD-10) codes identified the postoperative surgical and medical complications. Propensity score matching for age, gender, and Charlson Comorbidity Index was performed to control for potential confounding factors. Odds ratios and CI will be used to compare postoperative complication rates between the various groups. RESULTS The anterior_opioids group included 22,581 patients (45.5% male and 54.5% female) and the anterior_mix group included 2,192 patients (37.2% male and 62.8% female). The posterior_opioids group included 22,279 patients (48.0% male and 52.0% female) and the posterior_mix group included 2,677 patients (39.4% male and 60.6% female). After propensity score matching, the anterior groups and posterior groups were 2,182 and 2,671 patients, respectively. The incidence of postoperative pain at 6 weeks was higher in anteriormix (6.0%) than anterior_opioids (3.9%); similarly, this incidence was higher in posterior_mix (8.6%) than posterior_opioids (5.6%). The incidence of mental disorders at 3 weeks was higher in anterior_opioids (6.9%) than anterior_mix (5.8%), while the incidence of GI complications at 3 weeks was lower in anterior_opioids (3.1%) than anterior_mix (3.8%). Respiratory complications at 3 weeks were higher in posterior_mix (2.5%) than posterior_opioids (1.9%). Furthermore, neurologic complications at 3 weeks were higher in posterior_mix (2.3%) than posterior_opioids (1.9%). CONCLUSIONS Patients receiving opioids and Gabapentin or Pregabalin for postoperative pain management following ALIF had higher incidence of postoperative pain and GI complications, but lower incidence of mental disorders, compared to patients who received opioids. Patients who received a mixed regimen for postoperative pain management following PLIF or TLIF were associated with a higher incidence of postoperative pain, respiratory, and neurologic complications. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

COVID-19 is a severe infectious disease that has claimed >150,000 lives and infected millions in the United States thus far, especially the elderly population. Emerging evidence has shown the virus to cause hemorrhagic and immunologic responses, which impact all organs, including lungs, kidneys, and the brain, as well as extremities. SARS-CoV-2 also affects patients’, families’, and society’s mental health at large. There is growing evidence of re-infection in some patients. The goal of this paper is to provide a comprehensive review of SARS-CoV-2-induced disease, its mechanism of infection, diagnostics, therapeutics, and treatment strategies, while also focusing on less attended aspects by previous studies, including nutritional support, psychological, and rehabilitation of the pandemic and its management. We performed a systematic review of >1,000 articles and included 425 references from online databases, including, PubMed, Google Scholar, and California Baptist University’s library. COVID-19 patients go through acute respiratory distress syndrome, cytokine storm, acute hypercoagulable state, and autonomic dysfunction, which must be managed by a multidisciplinary team including nursing, nutrition, and rehabilitation. The elderly population and those who are suffering from Alzheimer’s disease and dementia related illnesses seem to be at the higher risk. There are 28 vaccines under development, and new treatment strategies/protocols are being investigated. The future management for COVID-19 should include B-cell and T-cell immunotherapy in combination with emerging prophylaxis. The mental health and illness aspect of COVID-19 are among the most important side effects of this pandemic which requires a national plan for prevention, diagnosis and treatment.

Background: Minimally invasive spine surgery (MISS) and endoscopic spine surgery have continually evolving indications in the cervical, thoracic, and lumbar spine. Endoscopic spine surgery entails treatment of disc disease, stenosis, spondylolisthesis, radiculopathy, and deformity. MISS involves complex motor skills in regions of variable anatomy. Simulator use has been proposed to aid in training and skill retention, preoperative planning, and intraoperative use. Methods: A systematic review of five databases was performed for publications pertaining to the use of virtual (VR), augmented (AR), and mixed (MR) reality in MISS and spinal endoscopic surgery. Qualitative data analysis was undertaken with focus of study design, quality, and reported outcomes. Study quality was assessed using the Medical Education Research Quality Instrument (MERSQI) score and level of evidence (LoE) by a modified Oxford Centre for Evidence-Based Medicine (OCEBM) level for simulation in medicine. Results: Thirty-eight studies were retained for data collection. Studies were of intervention-control, clinical application, and pilot or cross-sectional design. Identified articles illustrated use of VR, AR, and MR in all study designs. Procedures included pedicle cannulation and screw insertion, vertebroplasty, kyphoplasty, percutaneous transforaminal endoscopic discectomy (PTED), lumbar puncture and facet injection, transvertebral anterior cervical foraminotomy (TVACF) and posterior cervical laminoforaminotomy. Overall MERSQI score was low-to-medium [M =9.71 (SD =2.60); range, 4.5–13.5], and LoE was predominantly low given the number of purely descriptive articles, or low-quality randomized studies. Conclusions: The current scope of VR, AR, and MR surgical simulators in MISS and spinal endoscopic surgery was described. Studies demonstrate improvement in technical skill and patient outcomes in short term follow-up. Despite this, overall study quality and levels of evidence remain low. Cohesive study design and reporting with focus on transfer validity in training scenarios, and patient derived outcome measures in clinical studies are required to further advance the field.

With the health care environment becoming increasingly patient centric and cost-conscious, interest levels in spinal endoscopy are at an all-time high. Patient demand for the least invasive procedures combined with surgeon desire to maximally shorten the postoperative recovery period has further driven this surgical evolution. Mounting scientific evidence demonstrates the noninferiority and perhaps even superiority of endoscopic techniques to more conventional spinal surgery for the treatment of spinal stenosis and disc herniations. Although higher level evidence is much needed to support the clinical utility of the latest endoscopic techniques and surgical indications, it appears that the entrance of spinal endoscopy into the mainstream arena of spinal surgery is inevitable.

The presence of Propionibacterium acnes in a substantial component of resected disc specimens obtained from patients undergoing discectomy or microdiscectomy has led to the suggestion that this prominent human skin and oral commensal may exacerbate the pathology of degenerative disc disease. This hypothesis, therefore, raises the exciting possibility that antibiotics could play an important role in treating this debilitating condition. To date, however, little information about antibiotic penetration into the intervertebral disc is available.Intervertebral disc tissue obtained from 54 microdiscectomy patients given prophylactic cefazolin (n = 25), clindamycin (n = 17) or vancomycin (n = 12) was assayed by high-performance liquid chromatography, with cefaclor as an internal standard, to determine the concentration of antibiotic penetrating into the disc tissue.Intervertebral disc tissues from patients receiving the positively charged antibiotic clindamycin contained a significantly greater percentage of the antibacterial dose than the tissue from patients receiving negatively charged cefazolin (P 0.0001) and vancomycin, which has a slight positive charge (P 0.0001).Positively charged antibiotics appear more appropriate for future studies investigating potential options for the treatment of low-virulence disc infections. These slides can be retrieved under Electronic Supplementary Material.

Study Design: Case-control study. Objectives: Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord injury in adults aged over 55 years. However, since the onset is typically insidious, accurately diagnosing CSM can be challenging, often requiring referral to a subspecialist and advanced imaging. To help identify patients at risk for CSM, this case-control study compared responses to a series of 4 questions (DOWN questionnaire) in myelopathic and non-myelopathic patients. Methods: Ninety-two patients, 46 with and 46 without myelopathy, were recruited for the study. Each patient answered 4 questions encompassing common symptoms associated with CSM. Responses between patient groups were compared, and Cohen’s κ was used to assess for agreement between responses and the diagnosis of myelopathy. Results: We found a sensitivity of 91% and a κ of 0.54 to 3 positive responses and a sensitivity of 72% and a κ of 0.61 to 4 positive responses. Conclusions: Positive responses to 3 or more DOWN questions has high sensitivity and moderate agreement with the diagnosis of myelopathy based on history, physical exam, and review of advanced imaging by an orthopedic or neurological surgeon. The DOWN questionnaire is a potentially useful screening tool to identify patients at risk for CSM.

Background: The purpose of this study is to assess the incidence, risk factors for, and types of respiratory complications occurring in patients undergoing lumbar spine surgery. Methods: Patients undergoing various lumbar spine surgeries from 2007 to 2014 were identified using the PearlDiver patient record database from the nationwide insurance provider Humana Inc. Patient records were analyzed using International Classification of Diseases, Ninth Revision codes and Current Procedural Terminology codes to determine the incidence of pneumonia, pleural effusion, pulmonary collapse, and acute respiratory failure for each procedure type. The incidence of these complications in patients with the risk factors diabetes mellitus, chronic obstructive pulmonary disease (COPD), and smoking was also examined. Results: A total of 64,891 patients (33,280 females; 31,611 males) within the Humana database underwent various lumbar procedures from 2007 to 2014. The overall incidence of respiratory complications in patients undergoing lumbar procedures was 5.7% (n = 3694) within 1 month of having the procedure. Pulmonary collapse was the most common complication with an incidence of 4.3% (n = 2792), followed by pneumonia 1.98% (n = 1285), acute respiratory failure 1.97% (n = 1279), and pleural effusion 1.6% (n = 1048). For each respiratory complication studied, single level discectomy had the lowest complication rate and multilevel anterior lumbar interbody fusion had the highest complication rate. The incidence of each individual respiratory complication was higher in patients who had a history of smoking, COPD, or diabetes mellitus than it was in patients with none of these 3 risk factors (P Conclusion: The results of this study show that patients who have a history of smoking, COPD, or diabetes mellitus are at a greater risk for respiratory complications following lumbar spine surgery. These findings are useful for patient selection, clinical decision-making, and preoperative counseling.

Retrospective kinematic MRI (kMRI) study. To evaluate the dynamic changes of thoracic anterior and posterior space available for cord (SAC), and thoracic spinal cord in the dural sac in three positions. Expert MRI, Bellflower California; and University of Southern California, in Los Angeles, USA. A total of 118 patients (66 males and 52 females, mean age ( ± SD) of 45.6 ± 10.6 years) who underwent thoracic spine kMRI were evaluated from T4–5 to T11–12 in flexion, neutral, and extension positions. The anterior SAC, posterior SAC, and mid-sagittal thoracic cord diameter were measured at each level from T4–5 to T11–12. Inter- and intraobserver agreements were analyzed. The anterior SAC was significantly narrower in flexion position compared with other positions at T8–9 to T11–12 levels (p

Cervical sagittal vertical axis (cSVA) of ≥40 mm is recognized as the key factor of poor health-related quality of life, poor surgical outcomes, and correction loss after surgery for cervical deformity. However, little is known about the radiological characteristics of patients with cSVA≥40 mm.The purpose of this study was to identify the radiological characteristics of patients with cervical imbalance.Retrospective analysis of weight-bearing cervical magnetic resonance (MR) images.Consecutive 1,500 MR images of symptomatic patients in weight-bearing position.Cervical sagittal vertical axis, cervical alignment, cervical balance parameters (T1 slope, Co-C2 angle, C2-C7 angle, C7-T1 angle, neck tilt, and thoracic inlet angle), disc degeneration (Pfirmann and Suzuki classification), end plate degeneration (Modic change), spondylolisthesis (antero- and retrolisthesis), anteroposterior (AP) diameter of dural sac, cross-sectional area (CSA), and fat infiltration ratio of the transversospinalis muscles at C4 and C7 levels.Patients were divided into two groups: cSVA≥40 mm and cSVA40 mm. Gender, age, and cervical alignment were analyzed. Subsequently, matched imbalance (cSVA≥40 mm) and control (40 mm) groups were created using the propensity score to adjust for age, gender, and cervical alignment. Cervicothoracic angular parameters, disc degeneration, Modic change, spondylolisthesis, and degeneration of the transversospinalis muscles at C4 and C7 were compared. Variables with p.05 were included in the multinomial logistic regression model to identify factors that relate to the cervical balance grouping.The incidence of patients with cervical imbalance was 2.5% (37 patients). Those patients had a higher incidence of kyphosis, were older, and there were more male patients. In the matched imbalance group, the T1 slope was greater (p=.028), C7-T1 lordotic angle was smaller (p.001), the number of anterolisthesis was greater (p=.012), and the fat infiltration ratio at C4 and C7 was higher (p=.023, 0.030) compared with the control. Logistic regression analysis showed that the C7-T1 angle (adjusted odds ratio [aOR]=0.592, p=.001) and fat infiltration ratio at C7 level (aOR=1.178, p=.030) were significant independent variables.Smaller C7-T1 lordotic angle and severe muscle degeneration at C7 level were independent characteristics of patients with cervical imbalance.

Study DesignRetrospective, observational, case series.PurposeTo elucidate the prevalence of degenerative changes in the cervical and lumbar spine and estimate the degenerative changes in the cervical spine based on the degeneration of lumbar disc through a retrospective review of magnetic resonance (MR) images.Overview of LiteratureOver 50% of middle-aged adults show evidence of spinal degeneration. However, the relationship between degenerative changes in the cervical and lumbar spine has yet to be elucidated.MethodsA retrospective review of positional MR images of 152 patients with symptoms related to cervical and lumbar spondylosis with or without a neurogenic component was conducted. The degree of intervertebral disc degeneration (IDD) was assessed on a grade of 1–5 for each segment of the cervical and lumbar spine using MR T2-weighted sagittal images. The grades across all segments were summed to produce the degenerative disc score (DDS) for the cervical and lumbar spine. The patients were divided into two groups based on the IDD grade for each lumbar segment: normal (grades 1 and 2) and degenerative (grades 3–5).ResultsDDSs for the cervical and lumbar spine were positively correlated. Significant differences in cervical DDSs between the groups were observed in all lumbar segments. Although there were no significant differences in cervical DDSs among the degenerative lumbar segment, cervical DDSs at the L1–2 and L2–3 segments tended to be higher than those at the L3–4, L4–5, and L5–S degenerative segments.ConclusionsOur study shows that participants with degenerative changes in the upper lumbar segments are more likely to have a certain amount of cervical spondylosis. This information could be used to lower the incidence of a missed diagnosis of cervical spine disorders in patients presenting with lumbar spine symptomology.

To review the current understanding and data of sagittal balance and alignment considerations in paraplegic patients. A PubMed literature search was conducted to identify all relevant articles relating to sagittal alignment and sagittal balance considerations in paraplegic and spinal cord injury patients. While there are numerous studies and publications on sagittal balance in the ambulatory patient with spinal deformity or complex spine disorders, there is paucity of the literature on “normal” sagittal balance in the paraplegic patients. Studies have reported significantly alterations of the sagittal alignment parameters in the non-ambulatory paraplegic patients compared to ambulatory patients. The variability of the alignment changes is related to the differences in the level of the spinal cord injury and their differences in the activations of truncal muscles to allow functional movements in those patients, particularly in optimizing sitting and transferring. Surgical goal in treating paraplegic patients with complex pathologies should not be solely directed to achieve the “normal” radiographic parameters of sagittal alignment in the ambulatory patients. The goal should be to maintain good coronal balance to allow ideal sitting position and to preserve motion segment to optimize functions of paraplegia patients. Current available literature data have not defined normal sagittal parameters for paraplegic patients. There are significant differences in postural sagittal parameters and muscle activations in paraplegic and non-spinal cord injury patients that can lead to differences in sagittal alignment and balance. Treatment goal in spine surgery for paraplegic patients should address their global function, sitting balance, and ability to perform self-care rather than the accepted radiographic parameters for adult spinal deformity in ambulatory patients.

Purpose: The purpose of this study was to report trends, complications, and costs associated with endoscopic carpal tunnel release (ECTR) and open carpal tunnel release (OCTR). Methods: Using Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth Revision (ICD-9) codes, patients who had open versus endoscopic carpal tunnel release (CTR) were identified retrospectively in the PearlDiver database from both the Medicare and Humana (a private payer health insurance) populations from 2005 to 2014. These groups were then evaluated for postoperative complications, including wound infection within 90 days, wound dehiscence within 90 days, and intraoperative median nerve injury. We also used the data output for each group to compare the cost of the 2 procedure types. Data were analyzed via the Student t test. Statistical significance was set at P < .05. Results: A significantly lower percentage of patients in the endoscopic CTR group had a postoperative infection (5.21 vs 7.97 per 1000 patients per year, P < .001; 7.36 vs 11.23 per 1000 patients per year, P < .001) and wound dehiscence (1.58 vs 2.87 per 1000 patients per year, P < .001; 2.14 vs 3.73 per 1000 patients per year, P < .05) than open CTR group in the Medicare and Humana populations, respectively. Median nerve injury occurred 0.59/1000 ECTRs versus 1.69/1000 OCTRs (Medicare) and 1.96/1000 ECTRs versus 3.72/1000 OCTRs (Humana). Endoscopic CTR cost was more than open CTR for both the Medicare population ($1643 vs $1015 per procedure, P < .001) and Humana population ($1928 vs $1191 per procedure, P < .001). Conclusions: In both the Medicare and private insurance patient populations, endoscopic CTR is associated with fewer postoperative complications than open CTR, but is associated with greater expenses.

BACKGROUND CONTEXT Lumbar stenosis is a common spinal pathology and studies have shown that surgical treatment is often more effective than nonoperative management. Surgical options for the treatment of lumbar stenosis include decompression alone or decompression with fusion. Patients are often chosen for decompression with fusion when there is perceived instability; however, it is often unclear which radiographic parameters indicate instability requiring fusion. PURPOSE To evaluate the potential of motion metrics in predicting postop Patient Reported Outcomes (PROs) in patients with lumbar stenosis undergoing decompression with fusion or decompression alone. We hypothesize that patients with abnormal preoperative motion parameters will achieve better outcomes with decompression with fusion, and that patients with normal preop motion metrics will achieve better outcomes with decompression alone. STUDY DESIGN/SETTING Retrospective single center cohort study. PATIENT SAMPLE Patients treated for single level lumbar stenosis with spondylolisthesis by either decompression only or decompression plus fusion. OUTCOME MEASURES PROs (ODI, VAS and NRS), Angular Motion, Intervertebral Translation, Sagittal Plane Shear Index (SPSI), Spondylolisthesis Index, Anterior and Posterior Disc Integrity Index, Global ROM. METHODS This preliminary analysis includes 16/40 patients. Preop and 1-year postop flexion/extension X-ray images were analyzed with previously validated motion analysis software. Since the mechanical integrity of soft-tissues cannot be assessed unless the soft-tissues are sufficiently stressed, patients with RESULTS Of the 16 patients, 12 (75%) were female and 4 (25%) were male. Ages ranged from 33 to 77 years old with an average of 64 at the time of surgery. Two patients had surgery at L3-L4 (12%) and 14 had surgery at L4-L5 (88%). All 16 patients received decompression with fusion. The 95% confidence interval of a dataset that includes 384 radiographically normal asymptomatic volunteers was used to define normal limits of motion. SPSI > 2 indicates that the translation per degree of rotation was beyond the upper limit of normal. Preop SPSI was measured at 16 treatment levels and 50 non-treatment levels. Preop SPSI at the treatment level was 1.4±2.5 [-4.1 to 6.4] with 7 patients having SPSI>2 and 9 subjects having SPSI CONCLUSIONS SPSI is an objective measure of sagittal plane instability that may inform physicians of the need for fusion. In this preliminary analysis, the mean preop SPSI at the treatment level approached the upper limit of normal, while the mean at non-treatment levels was near the center of normal. There were 43.8% of patients who had abnormal preop SPSI values at the treatment level. Upon review of the PROs we will determine if preop SPSI is predictive of clinical outcome success, and if other novel metrics can be used along with SPSI to inform the optimal treatment pathway. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

To investigate the relationship between the facet fluid sign (FFS) and kinematics of affected lumbar segment in patients with low-grade, single-level lumbar degenerative spondylolisthesis using kinematic magnetic resonance imaging (kMRI).Materials and methods Ninety-two patients diagnosed with low-grade (Grade 1 or 2), single level lumbar degenerative spondylolisthesis L3 to S1. Angular and translational motion, whole lumbar motion, slip percentage, and facet angle were measured. Disc degeneration and degrees of osteoarthritis were graded, facet effusion was evaluated and classified as Positive or Negative FFS (PosFFS or NegFFS).Results There were significant differences in the facet degeneration, translational motion, percentage of total angular motion, and flexion-extension slip difference between the PosFFS and NegFFS group. 28.3% of the patients in PosFFS group had anterolisthesis in flexion, but not extension.There was a significant difference in the incidence of FFS between the dynamic and static spondylolisthesis (75% vs 35%, p 0.001). If FFS was present on kMRI, a positive predictive value for dynamic spondylolisthesis was 75.6%. with the sensitivity and specificity of 0.75 and 0.65 for posFFS to diagnose dynamic DS. The likelihood ratio for dynamic slips in the presence of FFS was 2.1, and the likelihood ratio for static slips in the presence of FFS was 1.1.Conclusion Facet fluid sign was present in weight-bearing neutral position, and the presence of FFS in kMRI increased the probability of having dynamic spondylolisthesis.

Degenerative cervical myelopathy (DCM) is a progressive spine disease and the most common cause of spinal cord dysfunction in adults worldwide. Patients with DCM may present with common signs and symptoms of neurological dysfunction, such as paresthesia, abnormal gait, decreased hand dexterity, hyperreflexia, increased tone, and sensory dysfunction. Clinicians across several specialties encounter patients with DCM, including primary care physicians, rehabilitation specialists, therapists, rheumatologists, neurologists, and spinal surgeons. Currently, there are no guidelines that outline how to best manage patients with mild (defined as a modified Japanese Orthopedic Association (mJOA) score of 15-17), moderate (mJOA = 12-14), or severe (mJOA ≤ 11) myelopathy, or nonmyelopathic patients with evidence of cord compression. This guideline provides evidence-based recommendations to specify appropriate treatment strategies for these populations. The intent of our recommendations is to (1) help identify patients at high risk of neurological deterioration, (2) define the role of nonoperative and operative management in each patient population, and (3) determine which patients are most likely to benefit from surgical intervention. The ultimate goal of these guidelines is to improve outcomes and reduce morbidity in patients with DCM by promoting standardization of care and encouraging clinicians to make evidence-informed decisions.

Background Context T1 slope is a novel thoracic parameter used to assess cervical spine sagittal balance. Thoracic index (TI) parameters including T1 slope and cervical sagittal alignment parameters may play an important role in degenerative cervical spondylolisthesis (DCS). Current literature regarding the relationship between TI and cervical sagittal alignment parameters in patients with DCS is limited. Purpose (1) To evaluate the T1 slope, cervical sagittal alignment, and thoracic inlet parameter in patients with DCS using kinematic magnetic resonance imaging (kMRI), and (2) to find a correlation between the T1 slope, TI, and other cervical sagittal parameters in patients with DCS. Design/Setting Retrospective kMRI study, Level III. Patient Sample Fifty-two patients with DCS from 1,128 patients from a cervical kMRI database. Outcome Measures T1 slope, C2–C7 angle, sagittal vertical axis C2–C7 (SVA C2–C7), cranial tilt, cervical tilt, neck tilt, and thoracic inlet angle (TIA). Methods Cervical spine kMRIs of 52 patients with DCS (mean age 51.7±standard deviation) were analyzed in neutral, flexion, and extension positions. Patients with DCS were divided into two groups: anterolisthesis (N=33) and retrolisthesis (N=19). Each listhesis group was subclassified into grade 1 (slip 2–3 mm) and grade 2 (slip>3 mm). Results Grade 2 retrolisthesis had the largest T1 slope followed by grade 1 retrolisthesis, grade 2 anterolisthesis, and grade 1 anterolisthesis. Significant differences were found between the anterolisthesis and the retrolisthesis groups in the neutral position (p=.025). The flexion position had the largest T1 slope and showed a significant difference with anterolisthesis in the neutral position (p=.041). Sagittal vertical axis C2–C7 showed strong correlation with cranial tilt in all DCS groups and all positions. Conclusions In our study, T1 slope was larger in grade 2 DCS, and the retrolisthesis group had larger T1 slope than the anterolisthesis group. Presence of larger T1 slope was significantly correlated with larger cervical lordosis curvature. Furthermore, cranial tilt was strongly correlated with SVA C2–C7.

Study DesignRetrospective analysis of a nationwide private insurance database. Chi-square analysis and linear regression models were utilized for outcome measures.PurposeThe purpose of this study was to investigate any relationship between lumbar degenerative disc disease, diabetes, obesity and smoking tobacco.Overview of LiteratureDiabetes, obesity, and smoking tobacco are comorbid conditions known to individually have effect on degenerative disc disease. Most studies have only been on a small populous scale. No study has yet to investigate the combination of these conditions within a large patient cohort nor have they reviewed the combination of these conditions on degenerative disc disease.MethodsA retrospective analysis of insurance billing codes within the nationwide Humana insurance database was performed, using PearlDiver software (PearlDiver, Inc., Fort Wayne, IN, USA), to identify trends among patients diagnosed with lumbar disc degenerative disease with and without the associated comorbidities of obesity, diabetes, and/or smoking tobacco. Patients billed for a comorbidity diagnosis on the same patient record as the lumbar disc degenerative disease diagnosis were compared over time to patients billed for lumbar disc degenerative disease without a comorbidity. There were no sources of funding for this manuscript and no conflicts of interest.ResultsThe total number and prevalence of patients (per 10,000) within the database diagnosed with lumbar disc degenerative disease increased by 241.4% and 130.3%, respectively. The subsets of patients within this population who were concurrently diagnosed with either obesity, diabetes, tobacco use, or a combination thereof, was significantly higher than patients diagnosed with lumbar disc degenerative disease alone (p p p ConclusionsDiabetes, obesity and cigarette smoking each are significantly associated with an increased diagnosis of lumbar degenerative disc disease. The combination of smoking and obesity had a synergistic effect on increased rates of lumbar degenerative disc disease. Patient education and preventative care is a vital goal in prevention of degenerative disc disease within the general population.