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Study Design: Single institution retrospective clinical review., Objective: To investigate the relationship between levels fused and clinical outcomes in patients undergoing open and minimally invasive surgical (MIS) lumbar fusion., Summary of Background Data: Minimally invasive spinal fusion aims to reduce the morbidity associated with conventional open surgery. As multilevel arthrodesis procedures are increasingly performed using MIS techniques, it is necessary to weigh the risks and benefits of multilevel MIS lumbar fusion as a function of fusion length., Methods: Patients undergoing <4 level lumbar interbody fusion were stratified by surgical technique (MIS or open), and grouped by fusion length: 1-level, 2-levels, 3+ levels. Demographics, Charlson Comorbidity Index (CCI), surgical factors, and perioperative complication rates were compared between technique groups at different fusion lengths using means comparison tests., Results: Included: 361 patients undergoing lumbar interbody fusion (88% transforaminal, 14% lateral; 41% MIS). Breakdown by fusion length: 63% 1-level, 22% 2-level, 15% 3+ level. Op-time did not differ between groups at 1-level (MIS: 233 min vs. Open: 227, P = 0.554), though MIS at 2-levels (332 min vs. 281) and 3+ levels (373 min vs. 323) were longer (P = 0.033 and P = 0.231, respectively). While complication rates were lower for MIS at 1-level (15% vs. 30%, P = 0.006) and 2-levels (13% vs. 27%, P = 0.147), at 3+ levels, complication rates were comparable (38% vs. 35%, P = 0.870). 3+ level MIS fusions had higher rates of ileus (13% vs. 0%, P = 0.008) and a trend of increased adverse pulmonary events (25% vs. 7%, P = 0.110). MIS was associated with less EBL at all lengths (all P < 0.01) and lower rates of anemia at 1-level (5% vs. 18%, P < 0.001) and 2-levels (7% vs. 16%, P = 0.193). At 3+ levels, however, anemia rates were similar between groups (13% vs. 15%, P = 0.877)., Conclusion: MIS lumbar interbody fusions provided diminishing clinical returns for multilevel procedures. While MIS patients had lower rates of perioperative complications for 1- and 2-level fusions, 3+ level MIS fusions had comparable complication rates to open cases, and higher rates of adverse pulmonary and ileus events., Level of Evidence: 3.

Patient-specific rods designed based on a particular pre-operative plan are a recent advancement to help achieve desired operative alignment goals. This study investigated the role of pre-operative planning and patient-specific rods on post-operative alignment and outcomes. Patients were grouped according to use of pre-operative planning and patient-specific, pre-contoured rods (PLAN) or absence of planning/rods (NON). Pre-operative and post-operative alignment were measured: cervical sagittal vertical axis (cSVA), cervical lordosis (CL), T1 Slope minus CL (TS-CL). Alignment differences between the groups were assessed using independent and paired samples t-tests. 34 patients were identified (15 PLAN, 19 NON). Pre- and post-operative CL, cSVA and TS were similar between the two groups (p > 0.05), though pre-operative TS-CL was slightly higher in PLAN patients (28.13° versus 18.42°, p = 0.049). There were no improvement differences pre- to post-operative for CL, cSVA and TS between the groups (p > 0.05). However, PLAN patients exhibited a greater correction of TS-CL, with an average of 5.8° decrease versus a 3.5° increase in TS-CL for NON patients (p = 0.015). PLAN patients did not demonstrate a significant change from pre- to post-operative alignment for cSVA or TS-CL (cSVA: 27.5 mm to 31.1 mm, p = 0.255; TS-CL: 28.1° to 22.3°, p = 0.13), though their TS-CL did trend towards significant post-operative improvement. In contrast, NON patients worsened in cSVA and TS-CL post-operatively (cSVA: 21.8 mm to 30.3 mm, p < 0.001; TS-CL: 18.4° to 22.0°, p = 0.035). Multi-segment posterior decompression and fusion patients have the potential to worsen with regards to post-operative alignment without pre-operative planning. Patients with pre-contoured rods and pre-operative planning exhibited a greater correction of TS-CL after surgery than un-planned cases, though limited by the pre-operative difference in cervical-thoracic mismatch between planned and unplanned cases. LEVELS OF EVIDENCE: III., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Study Design: Retrospective review of KID Inpatient Database (KID) from 2003, 2006, 2009, and 2012., Objectives: The aim of this study was to evaluate the impact of advances in spinal surgery on patient outcomes in the treatment of Scheuermann kyphosis (SK)., Summary of Background Data: SK is one of the most common causes of back pain in adolescents. Trends in diagnoses and surgical treatment and approach to SK have not been well described., Methods: SK patients aged 0-20 years in KID were identified by ICD-9 code 732.0. KID-supplied year- and hospital-trend weights were used to establish prevalence. Patient demographics, surgical details, and outcomes were analyzed with analysis of variance., Results: A total of 1,070 SK patients were identified (33.2% female), with increasing incidence of SK diagnosed from 2003 to 2012 (3.6-7.5 per 100,000, p < .001). The average age of operative patients was 16.1±2.0 years and did not change (16.27-16.06 years, p = .905). The surgical rate has not changed over time (72.8%-72.8%, p = .909). Overall, 96.3% of operative patients underwent fusion, with 82.2% of cases spanning ≥4 levels; in addition, 8.6% underwent an anterior-only surgery, 74.6% posterior-only, and 13.6% combined approach. From 2003 to 2012, rates of posterior-only surgeries increased (62.4%-84.4%, p < .001) whereas the rate of combined-approach surgeries decreased (37.6%-8.8%, p < .001). Overall complication rates for SK surgeries have decreased (2003: 20.9%; 2012: 11.9%, p = .029). Concurrently, the rate of ≥4-level fusions has increased (43.5%-89.6%, p < .001), as well as the use of Smith-Peterson (7.8%-23.6%, p < .001) and three-column osteotomies (0.0%-2.7%, p = .011). In subanalysis comparing posterior to combined approaches, complication rates were significantly different (posterior: 9.88%, combined: 19.46%, p = .005). Patients undergoing a combined approach have a longer length of stay (LOS) than patients undergoing a posterior-only approach (7.8 vs. 5.6 days, p < .001)., Conclusions: Despite unchanged demographics and operative rates in SK, there has been a shift from combined to isolated posterior approaches, with a concurrent increase in levels treated. A combined approach was associated with increased complication rates, LOS, and total charges compared to isolated approaches. Awareness of these inherent differences is important for surgical decision making and patient education., Levels of Evidence: Level III., (Copyright © 2018 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Introduction: Spondylolysis is an increasingly common diagnoses for young individuals and presents with a wide range of pathological and clinical findings. Most patients are treated conservatively, and surgery is reserved for severe cases. This is a populations study defining the incidence of spondylolysis in the Kids' Inpatient Database (KID) and assess trends in diagnoses, causes, and treatments., Methods: Retrospective analysis of the prospectively collected information in KID was performed for the years 2003 through 2012. Patients with a diagnosis of spondylolysis (ICD-9-CM 756.11) between the ages of 0 and 20 years in the KID were identified. Incidence of spondylolysis was established using KID-supplied hospital- and year-adjusted trend weights. Demographics including age, race, gender, and Charlson Comorbidity Index were assessed for all spondylolysis patients. Primary outcome measures were yearadjusted and hospital-adjusted incidence of spondylolysis. Secondary outcome measures were concurrent diagnoses and surgical details., Results: Six hundred and sixteen patients with a diagnosis of spondylolysis (329 with primary diagnosis) were identified (female: 53.8%; age: 15.27 ± 3.32 years). The incidence of spondylolysis is 7 per 100,000 patients nationally. Spondylolysis incidence has increased over time (p < 0.001) though the operative rate for spondylolysis has remained the same in the last decade (70% average, p = 0.52). The average CCI is 0.234, the average length of stay is 3.76 days and 92.4% of patients were discharged home. The etiology of the spondylolysis was trauma in 8.6% of patients (3.2% car crash, 1.9% pedestrian, 1.3% fall, 1.3% assault, 1.1% other transport, 1.0% sports, 0.3% motorcycle, 0.2% firearm, 0.2% bicycle; 1.9% reported multiple trauma etiologies). The most common concurrent diagnoses for all spondylolysis patients were spondylolisthesis (28%), idiopathic scoliosis (4.4%), cerebral palsy (1.9%), and spina bifida (1.8%). Four hundred and thirty patients with spondylolysis underwent surgical treatment and 40% of the surgically treated patients had spondylolisthesis. The rate of fusions was 54.9% fusions and 21% decompression, though the rate of fusions or decompressions being performed for spondylolysis has remained the same in the last decade (average fusion rate: 55%; average decompression rate: 18%; both p > 0.05). Levels fused and complications did not differ depending on whether or not decompression was performed (p > 0.05). The posterior-only approach was used in 62.2% of surgeries and were mostly 2 to 3 level procedures (63.5%). Perioperative complications occurred in 8.1% of patients, with the most common complications being device-related (2.3%), respiratory (1.5%), and digestive (1.5%)., Conclusions: The national incidence of spondylolysis has increased over time, and the surgical rate and treatment techniques have remained constant. The most common concurrent diagnoses were idiopathic scoliosis, cerebral palsy, and spina bifida. Further work is required to determine the significance of these trends and associations.

Background: Proximal junctional kyphosis (PJK) following adult spinal deformity (ASD) surgery is a well-documented complication, but associations between radiographic PJK and cervical malalignment onset remain unexplored., Objective: To study cervical malalignment in ASD surgical patients that develop PJK., Methods: Retrospective review of prospective multicenter database. Inclusion: primary ASD patients (≥5 levels fused, upper instrumented vertebra [UIV] at T2 or above, and 1-yr minimum follow-up) without baseline cervical deformity (CD), defined as ≥2 of the following criteria: T1 slope minus cervical lordosis < 20°, cervical sagittal vertical axis < 4 cm, C2-C7 cervical lordosis < 10°. PJK presence (<10° change in UIV and UIV + 2 kyphosis) and angle were identified 1 yr postoperative. Propensity score matching between PJK and nonPJK groups controlled for baseline alignment. Preoperative and 1-yr postoperative cervical alignment were compared between PJK and nonPJK patients., Results: One hundred sixty-three patients without baseline CD (54.9 yr, 83.9% female) were included. PJK developed in 60 (36.8%) patients, with 27 (45%) having UIV above T7. PJK patients had significantly greater baseline T1 slope in unmatched and propensity score matching comparisons (P < .05). At 1 yr postoperative, PJK patients had significantly higher T1 slope (P < .001), C2-T3 Cobb (P = .04), and C2-T3 sagittal vertical axis (P = .02). New-onset CD rate in PJK patients was 15%, and 16.5% in nonPJK patients (P > .05). Increased PJK magnitude was associated with increasing T1 slope and C2-T3 SVA (P < .05)., Conclusion: Patients who develop PJK following surgical correction of ASD have a 15% incidence of development of new-onset CD. Patients developing PJK following surgical correction of ASD tend to have an increased preoperative T1 slope. Increased progression of C2-T3 Cobb angle and C2-T3 SVA are associated with development of PJK following surgical correction of thoracolumbar deformity.

OBJECTIVE Most cervical fixations for atlantoaxial dislocation (AAD) are bilateral and symmetric; however, in the setting of osseous and vascular deformity at the craniovertebral junction, asymmetrical and hybrid fixations are used as "salvage" techniques. Because of the rarity of these cases, hybrid cervical fixations for AAD have not been fully explored. The aim of this study was to evaluate the clinical feasibility and outcomes of posterior hybrid cervical fixations for AAD. METHODS Twenty-one AAD cases were retrospectively studied; 18 had cervical myelopathy with Japanese Orthopaedic Association (JOA) scores ranging from 9 to 16 (mean 13.5). Hybrid fixation techniques included unilateral pedicle screws, transarticular screws, C-2 laminar screws, cervical lateral mass screws, and spinous process screws. During the same period, 82 AAD cases, treated using symmetric traditional fixations, were analyzed as controls. RESULTS Atlantoaxial fixation was performed in 11 cases, while occiput-cervical fixation was used in 10 cases. All cases achieved solid osseous fusion. Anatomical reduction was achieved in 20 cases (95.2%). All 18 cases with myelopathy showed postoperative improvement, with JOA scores ranging from 13 to 17 (mean 15.5). Three cases (14.2%) experienced complications, including delayed wound healing, CSF leakage, and fixation loosening. Hybrid fixation techniques showed significantly greater estimated blood loss when compared with controls (208.1 ± 19.30 ml vs 139.63 ± 8.75 ml, p = 0.001). Operative duration (125.38 ± 6.29 min vs 119.41 ± 3.77 min, p = 0.464), complication rates (14.3% vs 4.9%, p = 0.148), and JOA improvement rates (61% ± 7% vs 49% ± 4%, p = 0.161) showed no significant differences. CONCLUSIONS For ADD with osseous or vascular deformity, posterior cervical reduction and stabilization can be achieved using hybrid techniques, resulting in comparable clinical results to symmetric traditional fixation.

Background Context: Complication rates for adult cervical deformity are poorly characterized given the complexity and heterogeneity of cases., Purpose: To compare perioperative complication rates following adult cervical deformity corrective surgery between a prospective multicenter database for patients with cervical deformity (PCD) and the Nationwide Inpatient Sample (NIS)., Study Design/setting: Retrospective review of prospective databases., Patient Sample: A total of 11,501 adult patients with cervical deformity (11,379 patients from the NIS and 122 patients from the PCD database)., Outcome Measures: Perioperative medical and surgical complications., Methods: The NIS was queried (2001-2013) for cervical deformity discharges for patients ≥18 years undergoing cervical fusions using International Classification of Disease, Ninth Revision (ICD-9) coding. Patients ≥18 years from the PCD database (2013-2015) were selected. Equivalent complications were identified and rates were compared. Bonferroni correction (p<.004) was used for Pearson chi-square. Binary logistic regression was used to evaluate differences in complication rates between databases., Results: A total of 11,379 patients from the NIS database and 122 patiens from the PCD database were identified. Patients from the PCD database were older (62.49 vs. 55.15, p<.001) but displayed similar gender distribution. Intraoperative complication rate was higher in the PCD (39.3%) group than in the NIS (9.2%, p<.001) database. The PCD database had an increased risk of reporting overall complications than the NIS (odds ratio: 2.81, confidence interval: 1.81-4.38). Only device-related complications were greater in the NIS (7.1% vs. 1.1%, p=.007). Patients from the PCD database displayed higher rates of the following complications: peripheral vascular (0.8% vs. 0.1%, p=.001), gastrointestinal (GI) (2.5% vs. 0.2%, p<.001), infection (8.2% vs. 0.5%, p<.001), dural tear (4.1% vs. 0.6%, p<.001), and dysphagia (9.8% vs. 1.9%, p<.001). Genitourinary, wound, and deep veinthrombosis (DVT) complications were similar between databases (p>.004). Based on surgicalapproach, the PCD reported higher GI and neurologic complication rates for combined anterior-posterior procedures (p<.001). For posterior-only procedures, the NIS had more device-related complications (12.4% vs. 0.1%, p=.003), whereas PCD had more infections (9.3% vs. 0.7%, p<.001)., Conclusions: Analysis of the surgeon-maintained cervical database revealed higher overall and individual complication rates and higher data granularity. The nationwide database may underestimate complications of patients with adult cervical deformity (ACD) particularly in regard to perioperative surgical details owing to coding and deformity generalizations. The surgeon-maintained database captures the surgical details, but may underestimate some medical complications., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: To investigate the baseline patient characteristics, nonoperative modalities, surgical procedures, and complications rates of surgical cervical spondylotic myelopathy (CSM) patients. To evaluate risk factors for developing complications and compare the changes in health-related quality of life (HRQOL) from baseline to 2 years postoperatively., Methods: A retrospective review was performed on a prospectively collected database of CSM patients. Baseline patient demographic data, comorbidities, clinical information, nonoperative treatment modalities, surgical procedures, and complication rates were collected. HRQOL outcomes were assessed using the Short Form 36 (SF-36) Physical Score Component (PCS) and Mental Score Component (MCS) and the Neck Disability Index (NDI) at baseline and 2 years postoperatively. Statistical analyses included paired-sample t tests and multivariate logistic regression controlling for age, sex, and body mass index (BMI)., Results: A total of 203 surgical CSM patients were identified (43% female). Average age was 57.7 years and average BMI was 29.6 kg/m 2 . Before surgical intervention, patients underwent various nonoperative treatment modalities, most commonly nonsteroidal anti-inflammatory drugs (34%), analgesics (32%), and physical therapy (26%). The overall rate of complications was 7.4%. Complications included cerebrospinal fluid leak (2.5%), postoperative radiculopathy (1.0%), and excessive bleeding (1.0%). A previous history of cervical spine surgery was the sole significant risk factor for developing a complication (odds ratio, 9.22; P = 0.034). Average HRQOL scores improved significantly from baseline to 2 years postsurgery., Conclusions: The overall complication rate was 7.4% for the cohort. Baseline clinical information, comorbidities, use of nonoperative treatment modalities, and procedure type were not significantly associated with an increased risk of complications. Previous cervical spine surgery increased the risk of complications by 9-fold. The patients showed significantly improved SF-36 PCS, SF-36 MCS, and NDI scores at 2 years after surgery., (Copyright © 2017. Published by Elsevier Inc.)

Introduction: This study assessed the incidence and risk factors for pseudarthrosis among primary spine fusion patients. Methods: Retrospective review of ACS-NSQIP (2005--2013). Differences in comorbidities between spine fusion patients with and without pseudarthrosis (Pseud, N-Pseud) were assessed using chi-squared tests and Independent Samples t-tests. Binary logistic regression assessed patient-related and procedure-related predictors for pseudarthrosis. Results: 52,402 patients (57yrs, 53%F, 0.4% w/pseudarthrosis). Alcohol consumption (OR:2.6[1.2-5.7]) and prior history of surgical revision (OR:1.6[1.4-1.8]) were risk factors for pseudarthrosis operation. Pseud patients at higher risk for deep incisional SSI (at 30-days:OR:6.6[2.0--21.8]). Pseud patients had more perioperative complications (avg:0.24 ± 0.43v0.18 ± 0.39,p=0.026). Conclusions: Alcoholism and surgical revision are major risk factors for pseudarthrosis in patients undergoing spine fusion. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective review of prospectively collected data.Objective: To assess the clinical impact and economic burden of the three most common hospital-acquired conditions (HACs) that occur within 30-day postoperatively for all spine surgeries and to compare these rates with other common surgical procedures.Summary Of Background Data: HACs are part of a non-payment policy by the Centers for Medicare and Medicaid Services and thus prompt hospitals to improve patient outcomes and safety.Methods: Patients more than 18 years who underwent elective spine surgery were identified in American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2013. Primary outcomes were cost associated with the occurrence of three most common HACs. Cost associated with HAC occurrence derived from the PearlDiver database.Results: Ninety thousand five hundred fifty one elective spine surgery patients were identified, where 3021 (3.3%) developed at least one HAC. Surgical site infection (SSI) was the most common HAC (1.4%), then urinary tract infection (UTI) (1.3%) and venous thromboembolism (VTE) (0.8%). Length of stay (LOS) was longer for patients who experienced a HAC (5.1 vs. 3.2 d, P < 0.001). When adjusted for age, sex, and Charlson Comorbidity Index, LOS was 1.48 ± 0.04 days longer (P < 0.001) and payments were $8893 ± $148 greater (P < 0.001) for patients with at least one HAC. With the exception of craniotomy, patients undergoing common procedures with HAC had increased LOS and higher payments (P < 0.001). Adjusted additional LOS was 0.44 ± 0.02 and 0.38 ± 0.03 days for total knee arthroplasty and total hip arthroplasty, and payments were $1974 and $1882 greater. HACs following hip fracture repair were associated with 1.30 ± 0.11 days LOS and $4842 in payments (P < 0.001). Compared with elective spine surgery, only bariatric and cardiothoracic surgery demonstrated greater adjusted additional payments for patients with at least one HAC ($9975 and $10,868, respectively).Conclusion: HACs in elective spine surgery are associated with a substantial cost burden to the health care system. When adjusted for demographic factors and comorbidities, average LOS is 1.48 days longer and episode payments are $8893 greater for patients who experience at least one HAC compared with those who do not.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Conflicting reports exist in spine literature regarding short-term outcomes following cervical laminoplasty and posterior laminectomy and fusion. PURPOSE The objective of this study was to compare the 30-day outcomes for these two treatment groups for multilevel cervical pathology. STUDY DESIGN/SETTING Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database years 2010-2015. PATIENT SAMPLE A total of 3,796 patients were included: 2,397 (63%) underwent cervical laminectomy and fusion and 1,399 (37%) underwent cervical laminoplasty. OUTCOME MEASURES Patient demographics, comorbidities, complications and outcomes compared between patients undergoing cervical laminoplasty or laminectomy and fusion. METHODS Patients who underwent cervical laminoplasty or posterior laminectomy and fusion were identified in the NSQIP database from 2010 to 2015 based on Current Procedural Terminology (CPT) code. Laminoplasty CPT codes included 63050 and 63051. Posterior cervical laminectomy CPT codes included 63015, 63045, and instrumentation was denoted by CPT code 22842. Patients with preoperative sepsis, wound infection, pneumonia, cancer, emergency cases and trauma, and surgery within the last 30days were excluded. Patient demographics and comorbidities were compared using bivariate logistic regression. Propensity-adjusted multivariate regressions were performed to assess differences in postoperative length of stay, adverse events, discharge disposition and readmission. RESULTS A total of 3,796 patients were included: 2,397 (63%) underwent cervical laminectomy and fusion and 1,399 (37%) underwent cervical laminoplasty. Both groups were similar in age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) score and Charlson Comorbidity Index (CCI) (P>.05 for all). Both groups had similar rates of malnutrition, chronic kidney disease (CKD), diabetes, chronic obstructive pulmonary disease, and history for steroid use. Age >70 and age <50 were not associated with one treatment group over the other (P>.05 for all). Compared with laminoplasty patients, laminectomy and fusion patients had increased lengths of stay (LOS) (4.5vs. 3.7days, P<.01) and increased rates of adverse events (41.7vs. 35.9%, P<.01), discharge to rehab (16.4vs. 8.6%, P<.01) and skilled nursing facilities (12.2vs. 9.7%, P=.02), and readmission (6.2vs. 4.5%, P=.05). Both groups experienced similar rates of death, pulmonary embolus, deep vein thrombosis, deep and superficial surgical site infection and reoperation P>.05 for all). Patients with CKD that underwent laminectomy and fusion had higher rates of transfusion (6.8vs. 20.4%, P=.05). Patients older than 70 that underwent laminectomy and fusion experienced high rates of urinary tract infection (6.4vs. 2.6%, P=.02). CONCLUSIONS Posterior cervical laminectomy and fusion patients were found to have increased LOS, readmissions, and complications despite having similar preoperative demographics and comorbidities. Patients and surgeons should consider these risks when considering surgical treatment for cervical pathology. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Increased usage of computer adaptive testing such as Patient Reported Outcome Measurement Information System (PROMIS) aims to improve the capture of high quality patient outcomes. Recent work has shown correlations between PROMIS and the Oswestry Disability Index (ODI), but not specifically in a thoracolumbar population using the PROMIS Physical Function, Pain Intensity and Pain Interference computer adaptive domains. PURPOSE The aim of this study was to study the relationship between PROMIS and ODI scores in thoracolumbar patients. STUDY DESIGN/SETTING Retrospective review of single institution clinical data and patient-reported outcome measures. PATIENT SAMPLE A total of 208 spine patients with a thoracolumbar (TL) diagnosis. OUTCOME MEASURES Legacy metrics: Oswestry Disability Index (ODI), PROMIS. METHODS Inclusion was patients greater than 18years with a diagnosis related to the thoracolumbar spine (stenosis, disc herniation, low back pain, disc degeneration, spondylolysis most commonly). Bivariate correlations assessed the linear relationships between ODI and PROMIS scores (Physical Function, Pain Intensity and Pain Interference). Linear regression predicted the relationship of ODI to PROMIS outcomes. Statistical significance was set at P<.05. RESULTS A total of 208 patients with a thoracolumbar diagnosis were included (age 58.39±73.32years, 49% female). ODI strongly correlated with PROMIS Physical Function (r=−0.737, P<.001), PROMIS Pain Interference (r=0.790, P<.001), and PROMIS Pain Intensity (r=0.668, P<.001). Visual analog scale back is correlated with each of the three components of PROMIS assessed, most strongly with Pain Intensity (r=0.673, P<.001), though still did correlate with Physical Function (r=−0.472, P<.001) and Pain Interference (r=0.568, P<.001). ODI scores of TL patients strongly predicted PROMIS scores for Physical Function (R2=0.54, P<.001), Pain Intensity (R2=0.45, P<.001) and most strongly Pain Interference (R2=0.62, P<.001), and thus PROMIS domains predict ODI. CONCLUSIONS The well-established patient reported outcome ODI correlated strongly with PROMIS domains. ODI score strongly predicts PROMIS scores for all three components (Physical Function, Pain Intensity, Pain Interference) for thoracolumbar spine patients. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Common indications for transforaminal lumbar interbody fusion (TLIF) include foraminal stenosis, degenerative disc disease and spondylolisthesis. Although minimally invasive surgical techniques (MIS) for TLIF have been shown to provide adequate postoperative sagittal alignment, it is unclear whether these procedures result in adequate reduction of canal compressive forces. PURPOSE Assess baseline to postoperative changes in cross-sectional canal area in patients undergoing minimally invasive transforaminal lumbar interbody fusion. STUDY DESIGN/SETTING Retrospective clinical review of a prospective surgeon-maintained MIS database. PATIENT SAMPLE A total of 16 patients undergoing MIS TLIF. OUTCOME MEASURES Spinal canal cross-sectional area, stenotic levels. METHODS Consecutive patients >18years undergoing transforaminal lumbar interbody fusion via minimally invasive surgical technique were included. Patients with preoperative lumbar MRIs and postoperative lumbar MRI or CT scans were assessed for spinal canal cross sectional area at operative interspace levels. Stenotic levels were defined as canal cross sectional area <130 mm2, as previously published. All measurements were conducted using dedicated imaging software. Baseline to postoperative changes in canal cross sectional area was assessed using parametric and nonparametric means comparison tests, as appropriate. Significance was set to p<.05. RESULTS Overall, 16 patients met inclusion criteria and underwent minimally invasive transforaminal lumbar interbody fusion. Mean patient age was 54.3±12.1years, 63% of patients were female, and mean Charlson Comorbidity Index score was 0.86±1.10. Patients presented with three primary diagnoses: herniated nucleus pulposis (36.8%), stenosis (42.1%) and spondylosis (21.1%). On average, patients underwent fusions spanning 1.69±1.13 levels, and 37.5% of patients underwent multilevel fusion. 93.7% of cases involved laminotomy, 31.3% laminectomy, 81.3% foraminotomy. Mean operative time was 349 minutes and blood loss was 389±486 ccs. From baseline to postoperative intervals, 87.5% of patients showed an increase in mean operative interspace canal cross sectional area, with the overall cohort showing significant improvement in canal cross sectional area (207.6 mm2 to 301.6 mm2, p<.001). These changes corresponded with a decreased rate of postoperative stenosis, from 25.0% at baseline to 0.0% postoperative. While single-level and multilevel fusion patients all showed significant baseline to postoperative improvements in cross-sectional canal area (226 mm2 to 244 mm2, and 196 mm2 to 275 mm2, respectively, both p<.025), multilevel patients showed a greater pre- to postoperative change in canal cross-sectional area (118 mm2 vs. 79 mm2), although this difference did not reach statistical significance (p=.347). CONCLUSIONS Following minimally invasive transforaminal lumbar interbody fusion, patients showed a significant increase in spinal canal cross sectional area. This increase in canal cross sectional area corresponded with an overall decrease in the rate of lumbar stenosis, suggesting MIS TLIF procedures have the potential to provide adequate relief of spinal canal compressive forces. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Minimally invasive surgical (MIS) techniques for spinal fusion aim to reduce the morbidity and considerable soft-tissue damage associated with conventional open surgery. As longer, multilevel arthrodesis procedures are increasingly performed using MIS techniques, it is necessary to weigh the risks and benefits of multilevel MIS lumbar fusion as a function of fusion length. PURPOSE Investigate the relationship between number of levels fused and clinical outcomes in patients undergoing open and MIS lumbar fusion procedures. STUDY DESIGN/SETTING Retrospective clinical review at single institution. PATIENT SAMPLE A total of 437 patients undergoing lumbar interbody fusion by open or MIS technique. OUTCOME MEASURES Complication rates, length of stay (LOS), estimated blood loss (EBL) METHODS Patients undergoing <4 level lumbar interbody fusion were stratified by surgical technique (MIS or open), and subsequently grouped by fusion length: 1-level, 2-levels, 3+ levels. Hybrid cases were excluded. Patient demographics, Charlson Comorbidity Index (CCI) scores, surgical factors, and perioperative complication rates were compared between MIS and open cases at different fusion lengths using parametric and non-parametric means comparison tests, as appropriate. RESULTS Included: 437 patients (57±13 years, 51% F, 29.5 kg/m2) undergoing lumbar interbody fusion(1.6±0.9 levels fused, 72% involved transforaminal approach, 18% anterior, 14% lateral). Overall breakdown of fusion length groups was: 64% 1-level, 21% 2-level, 16% 3+ level. By surgical technique, 37.5% of cases were MIS and 62.5% were open. Patients undergoing open surgery were older (58 years vs. 55, p=.022) with more comorbidities(mean CCI: 1.5 vs. 0.9, p<.001) than MIS patients. Operative time did not differ between MIS and open patients at 1-level (MIS: 232 minutes vs. Open: 235, p=.684); however, MIS cases at 2-levels (322 minutes vs. 298) and 3+ levels (373 minutes vs. 343) were clinically, but not statistically, longer in duration (both p>.05). While periop complication rates were significantly lower for MIS patients at 1-level (16% vs. 29%, p=.012) and 2-levels (12% vs. 30%, p=.043), at 3+ levels, complication rates were comparable between MIS and open groups (38% vs. 36%, p=.921). Furthermore, despite no differences in rates of pulmonary and GI complications between MIS and open groups at 1-level and 2-levels (both p>.05), MIS patients undergoing 3+ level fusions had higher rates of ileus (13% vs. 0%, p=.003) and showed a trend of increased adverse pulmonary events (25% vs. 6%, p=.052). For all categories of fusion length, MIS procedures resulted in significantly less blood loss (all p<.01), corresponding with lower rates of anemia at 1-level (5% vs. 14%, p=.012) and 2-levels (3% vs. 16%, p=.055). At 3+ levels, however, anemia complication rates were similar between MIS and open patients (13% vs. 14%, p=.891). Inpatient LOS and ICU LOS were longer for open procedures at all fusion lengths (all p<.015). CONCLUSIONS As compared to corresponding open surgeries, minimally invasive lumbar interbody fusions provided diminishing clinical returns for multilevel procedures. While MIS patients had lower rates of perioperative complications for 1- and 2-level fusions, 3+ level MIS fusions resulted in overall complication rates comparable to those of open patients, and higher rates of adverse pulmonary and ileus events. These results can be used to improve counseling of patients indicated for multilevel lumbar interbody fusion. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]