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Study Design: Retrospective large database study. Objective: To determine the impact of cirrhosis on perioperative outcomes and resource utilization in elective spinal fusion surgery. Methods: Elective spinal fusion hospitalizations in patients with and without cirrhosis were identified using ICD-9-CM codes between the years of 2009 and 2011 using the Nationwide Inpatient Sample database. Main outcome measures were in-hospital neurologic, respiratory, cardiac, gastrointestinal, renal and urinary, pulmonary embolism, wound-related complications, and mortality. Length of stay and inpatient costs were also collected. Multivariable logistic regressions were conducted to compare the in-hospital outcomes of patients with and without cirrhosis undergoing spinal fusion. Results: A total of 1 214 694 patients underwent elective spinal fusions from 2009 to 2011. Oh these, 6739 were cirrhotic. Cirrhosis was a significant independent predictor for respiratory (odds ratio [OR] = 1.43, confidence interval [CI] 1.29-1.58; P < .001), gastrointestinal (OR = 1.72, CI 1.48-2.00; P < .001), urinary and renal (OR = 1.90, CI 1.70-2.12; P < 0.001), wound (OR = 1.36, CI 1.17-1.58; P < 0.001), and overall inpatient postoperative complications (OR = 1.43, CI 1.33-1.53; P < .001). Cirrhosis was also independently associated with significantly greater inpatient mortality (OR = 2.32, CI 1.72-3.14; P < .001). Cirrhotic patients also had significantly longer lengths of stay (5.35 vs 3.35 days; P < .001) and inpatient costs ($36 738 vs $29 068; P < .001). Conclusions: Cirrhosis is associated with increased risk of perioperative complications, mortality and greater resource utilization. Cirrhotic patients undergoing spinal fusion surgeries should be counseled on these increased risks. Current strategies for perioperative management of cirrhotic patients undergoing spinal fusion surgery need improvement.

Study Design: Retrospective database study. Objective: To investigate the impact obstructive sleep apnea (OSA) has on perioperative complications, inpatient mortality, and costs in patients undergoing spinal fusions. Methods: Hospitalizations for spinal fusion surgery between the years 2009 and 2011 were identified using the Nationwide Inpatient Sample and grouped into patients with and without OSA. Patient demographic data, comorbidities, hospital characteristics, hospitalization outcomes, and costs were extracted and compared. Multivariable logistic regressions were conducted to compare the in-hospital outcomes of patients undergoing spinal fusion with and without OSA. Results: A total of 107 451 (7.7%) OSA patients who underwent spinal fusions were identified from 2009 to 2011. Compared with patients without OSA, OSA patients were significantly older, more likely to be male, and have significantly greater comorbidity burden. Multivariable regression analysis demonstrated that OSA had a significant independent association with slightly increased respiratory (odds ratio [OR] = 1.13, confidence interval [CI] = 1.09-1.16; P < .001), urinary and renal (OR = 1.11, CI = 1.07-1.16; P < .001) or overall inpatient complications (OR = 1.05, CI = 1.02-1.05; P < .001). OSA was also independently associated with significantly lower inpatient mortality (OR = 0.39, CI = 0.33-0.45; P < .001). Conclusions: While OSA confers greater comorbidity burden and is associated with slightly higher inpatient complication rates following spinal fusions, diagnosed OSA was not an independent predictor of inpatient mortality. A cautious interpretation of this finding is that on a national level, the current methods of preoperative medical optimization and inpatient management of OSA are satisfactory.

Study Design: Retrospective chart review. Objectives: To evaluate the efficacy of tobramycin and vancomycin powder in reducing surgical site infections in posterior lumbar instrumented fusion. Methods: A multicenter, electronic database search was conducted for all patients who underwent posterior instrumented lumbar fusions. Results: The addition of vancomycin powder decreased postoperative infections from an incidence of 5.7% down to a rate of 2.0%. This difference was statistically significant (P = .018). The addition of tobramycin powder to the wound in addition to vancomycin further decreased the infection rate down to 1.8%. The postoperative infection rate was statistically significant (P = .041) when compared with the no-powder group. However, the difference was not statistically significant (P = 1.00) when compared with vancomycin alone. There was also a trend toward gram-negative organisms with the addition of more antibiotic powder. In the control group, for example, the organisms cultured were 66% methicillin-sensitive Staphylococcus aureus and 33% gram-negative organisms. In the vancomycin group, 30% of the organisms cultured were Staphylococcus aureus and 60% gram-negative organisms. In the vancomycin and tobramycin powder group, 100% of the organisms cultured were gram-negative. Conclusions: There is a reduction in surgical site infections with addition of antibiotic powder to the wound prior to closure. However, the reduction in the infection rate was not as great with the addition of tobramycin powder to vancomycin alone and there was a noticeable change in the spectrum of organism cultured with this addition. Clinicians should consider the risk-to-benefit ratio in each case when deciding to use antibiotic powder.

STUDY DESIGN A retrospective study. OBJECTIVE To determine the impact of sickle cell anemia on perioperative outcomes and resource utilization in elective spinal fusion surgery. SUMMARY OF BACKGROUND DATA Sickle cell anemia has been identified as an important surgical risk factor in otolaryngology, cardiothoracic surgery, general surgery, and total joint arthroplasty. However, the impact of sickle cell anemia on elective spine surgery is unknown. METHODS Hospitalizations for elective spinal fusion surgery between the years of 2001-2014 from the US National Inpatient Sample were identified using ICD-9-CM codes and patients were grouped into those with and without sickle cell anemia. The main outcome measures were in-hospital neurological, respiratory, cardiac, gastrointestinal, renal and urinary, pulmonary embolism, and wound-related complications and mortality. Length of stay and inpatient costs were also collected. Multivariable logistic regressions were conducted to compare the in-hospital outcomes of patients undergoing elective spinal fusion with or without sickle cell anemia. RESULTS From a total of 4,542,719 patients undergoing elective spinal fusions from 2001 to 2014, 456 sickle cell disease patients were identified. Sickle cell anemia is a significant independent predictor for pulmonary embolism [odds ratio (OR)=7.37; confidence interval (CI), 4.27-12.71; P

Background: As a growing number of patients seek consultations for increasingly complex and costly spinal surgery, it is of both clinical and economic value to investigate the role for second opinions (SOs). Here, we summarized and focused on the shortcomings of 14 studies regarding the role and value of SOs before proceeding with spine surgery. Methods: Utilizing PubMed, Google Scholar, and Scopus, we identified 14 studies that met the inclusion criteria that included: English, primary articles, and studies published in the past 20 years. Results: We identified the following findings regarding SO for spine surgery: (1) about 40.6% of spine consultations are SO cases; (2) 61.3% of those received a discordant SO; (3) 75% of discordant SOs recommended conservative management; and (4) SO discordance applied to a variety of procedures. Conclusion: The 14 studies reviewed regarding SOs in spine surgery showed that half of the SOs differed from those given in the initial consultation and that SOs in spine surgery can have a substantial impact on patient care. Absent are prospective studies investigating the impact of following a first versus second opinion. These studies are needed to inform the potential benefit of universal implementation of SOs before major spine operations to potentially reduce the frequency and type/extent of surgery.

BACKGROUND CONTEXT Bone graft extenders are being used more in spine surgery as a substitute for iliac crest bone graft, but potential conflict of interest could impact how the fusion rates are reported. PURPOSE To evaluate if the reported fusion rates are significantly greater in studies where there are potential conflicts of interest versus studies where there are no conflicts of interest. STUDY DESIGN/SETTING Meta-analysis PATIENT SAMPLE Comparison between studies where there were no reported conflicts of interest versus studies where there were reported conflicts of interest. OUTCOME MEASURES Reported fusion rates in the studies. METHODS PubMed was searched for studies evaluating fusion rates when bone graft extenders including demineralized bone matrix and hydroxyapatite and tricalcium sulfate are used as bone graft extenders with laminectomy bone. Studies were screened for one- or two-level fusions and for degenerative spinal conditions. RESULTS A total of 1,928 studies were evaluated with 86 studies included in the study. The fusion rates varied from 4% to 100%. There were 24 studies where there was a potential conflict of interest and 62 studies where there was no conflict of interest. There were 1,308 total patients in the studies where there was a potential conflict of interest and 3,696 patients in studies without conflict of interest. The fusion rates of all the studies combined was 84.63%. The fusion rates of those studies where there was a conflict of interest was 80.93% versus 86.06% when there was no conflict of interest, this was not statistically significant (p>0.07). The fusion rates with CT was 79.79% vs 87.94% when there was no CT. The fusion rates when there was an independent reviewer was 82.61% vs 85.63% when there was no independent reviewer. CONCLUSIONS There is a great variability in the reported fusion rates of bone graft extenders. The reported fusion rates were actually lower in the studies where there was a potential conflict of interest. This is counter to what would be expected. The use of CT scans and an independent reviewer seem to account for the lower reported fusion rates. The use of CT scans and independent reviewers may be a means of negating the potential conflicts of interest in fusion studies. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

The practice of contemporary pain medicine is laced with a number of significant ethical challenges. Considerable difficulties include the overutilization of interventional procedures, the application of under-evidenced treatment modalities, and potentially superfluous opioid prescribing. As with many other fields in medicine, including orthopedic surgery, relationships with industry are both common and pervasive, and influence our medical practice through education, publications, and research. This article highlights these ethical challenges and broaches several physician-driven solutions: The Association for Medical Ethics, the Physicians Payment Sunshine inspired by it, and other non-legislative reforms are discussed.

H.L. Mencken wrote that ‘‘When somebody says it’s not about money. It’s about the money.’’ Once again, the issue is about the money. Five years ago, I founded the Association for Medical Ethics (AME), calling for full disclosure of all money paid to researchers by manufacturers. Over those past 5 years, I have often heard ‘‘It’s the principle, not the money,’’ from defensive clinical researchers and industry folks. Would any reasonable person believe what I write when my article is about a product whose manufacturer is paying me? Well, if it is a little money say for implant expenses for testing you will probably have more confidence than if it is millions of dollarsdwith large sum comes large doubts. In those cases, you will probably reserve judgment on using the product and first perform the necessary due diligence to confirm the findings independently. This scenario may be a big problem for industries with marginal products who have a low expectation that initial company data will stand up to independent surveillance and analysis. Conversely, companies with substantial confidence in product performance have little to fear if surgeons choose conservative ‘‘wait and see’’ attitudes and do not jump right in there using the new product. Most prudent doctors will ‘‘wait and see’’ when they detect the influence of something other than independent unbiased literature from a historically trusted source in medicine. ‘‘Wait and see’’ can be very bad for launching new products because as industry folks say, ‘‘what ruins all those good papers is follow-up.’’ Unless practice patterns have already been changed to adopt the product in the absence of independent data, if complications and bad results surface in articles with generalized use, the battle to launch a new product with efficacy or safety problems is lost. It should not be surprising then that the solution for some company executives to prevent hindering profit making is to sweep these problems (complications) under the rug

This study compared 50 patients with lumbar facet fractures and continued pain after lumbar laminectomy with a postlaminectomy control group without facet fractures. Computed tomographic analysis compared variables including direct measurements of bone resection. Average follow-up between surgery and postsurgical computed tomographic examination was 3.2 years. In the fracture group, more than one half of the bone immediately above the flare of the inferior articular process at the level of the laminectomy, measured in a medial to lateral direction, had been resected. No one in the control group had more than one quarter of this bone removed (P = .0001). Lumbar facet fractures may be one cause of late postlaminectomy pain. Caution in resection of a particular area of bone may avoid this problem.