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Objective: Postoperative length of stay (LOS) significantly contributes to healthcare costs and resource utilization. The primary goal of this study was to identify patient, clinical, surgical, and institutional variables that influence LOS after elective surgery for degenerative conditions of the cervical spine. The secondary objectives were to examine the variability in LOS and institutional practices used to decrease LOS., Methods: This was a multicenter observational retrospective cohort study of patients enrolled in the Canadian Spine Outcomes and Research Network (CSORN) between January 2015 and October 2020 who underwent elective anterior cervical discectomy and fusion (ACDF) (1-3 levels) or posterior cervical fusion (PCF) (between C2 and T2) with/without decompression for degenerative conditions of the cervical spine. Prolonged LOS was defined as LOS greater than the median for the ACDF and PCF populations. The principal investigators at each participating CSORN healthcare institution completed a survey to capture institutional practices implemented to reduce postoperative LOS., Results: In total, 1228 patients were included (729 ACDF and 499 PCF patients). The median (IQR) LOS for ACDF and PCF were 1.0 (1.0) day and 5.0 (4.0) days, respectively. Predictors of prolonged LOS after ACDF were female sex, myelopathy diagnosis, lower baseline SF-12 mental component summary score, multilevel ACDF, and perioperative adverse events (AEs) (p < 0.05). Predictors of prolonged LOS after PCF were nonsmoking status, education less than high school, lower baseline numeric rating scale score for neck pain and EQ5D score, higher baseline Neck Disability Index score, and perioperative AEs (p < 0.05). Myelopathy did not significantly predict prolonged LOS within the PCF cohort after multivariate analysis. Of the 8 institutions (57.1%) with an enhanced recovery after surgery (ERAS) protocol or standardized protocol, only 3 reported using an ERAS protocol specific to patients undergoing ACDF or PCF., Conclusions: Patient and clinical factors predictive of prolonged LOS after ACDF and PCF are highly variable, warranting individual consideration for possible mitigation. Perioperative AEs remained a consistent independent predictor of prolonged LOS in both cohorts, highlighting the importance of preventing intra- and postoperative complications.

Objective: To examine differences in surgical practices between salaried and fee-for-service (FFS) surgeons for two common degenerative spine conditions. Surgeons may offer different treatments for similar conditions on the basis of their compensation mechanism., Methods: The study assessed the practices of 63 spine surgeons across eight Canadian provinces (39 FFS surgeons and 24 salaried) who performed surgery for two lumbar conditions: stable spinal stenosis and degenerative spondylolisthesis. The study included a multicenter, ambispective review of consecutive spine surgery patients enrolled in the Canadian Spine Outcomes and Research Network registry between October 2012 and July 2018. The primary outcome was the difference in type of procedures performed between the two groups. Secondary study variables included surgical characteristics, baseline patient factors, and patient-reported outcome., Results: For stable spinal stenosis ( n = 2234), salaried surgeons performed statistically fewer uninstrumented fusion ( p < 0.05) than FFS surgeons. For degenerative spondylolisthesis ( n = 1292), salaried surgeons performed significantly more instrumentation plus interbody fusions ( p < 0.05). There were no statistical differences in patient-reported outcomes between the two groups., Conclusions: Surgeon compensation was associated with different approaches to stable lumbar spinal stenosis and degenerative lumbar spondylolisthesis. Salaried surgeons chose a more conservative approach to spinal stenosis and a more aggressive approach to degenerative spondylolisthesis, which highlights that remuneration is likely a minor determinant in the differences in practice of spinal surgery in Canada. Further research is needed to further elucidate which variables, other than patient demographics and financial incentives, influence surgical decision-making.

Objective: Anterior cervical discectomy and fusion (ACDF) is often described as the gold standard surgical technique for cervical spondylotic radiculopathy. Although outcomes are considered favorable, there is little prognostic evidence to guide patient selection for ACDF. This study aimed to 1) describe the 24-month postoperative trajectories of arm pain, neck pain, and pain-related disability; and 2) identify perioperative prognostic factors that predict trajectories representing poor clinical outcomes., Methods: In this retrospective cohort study, patients with cervical spondylotic radiculopathy who underwent ACDF at 1 of 12 orthopedic or neurological surgery centers were recruited. Potential outcome predictors included demographic, health, clinical, and surgery-related prognostic factors. Surgical outcomes were classified by trajectories of arm pain intensity, neck pain intensity (numeric pain rating scales), and pain-related disability (Neck Disability Index) from before surgery to 24 months postsurgery. Trajectories of postoperative pain and disability were estimated with latent class growth analysis, and prognostic factors associated with poor outcome trajectory were identified with robust Poisson models., Results: The authors included data from 352 patients (mean age 50.9 [SD 9.5] years; 43.8% female). The models estimated that 15.5%-23.5% of patients followed a trajectory consistent with a poor clinical outcome. Lower physical and mental health-related quality of life, moderate to severe risk of depression, and longer surgical wait time and procedure time predicted poor postoperative trajectories for all outcomes. Receiving compensation and smoking additionally predicted a poor neck pain outcome. Regular exercise, physiotherapy, and spinal injections before surgery were associated with a lower risk of poor disability outcome. Patients who used daily opioids, those with worse general health, or those who reported predominant neck pain or a history of depression were at greater risk of poor disability outcome., Conclusions: Patients who undergo ACDF for cervical spondylotic radiculopathy experience heterogeneous postoperative trajectories of pain and disability, with 15.5%-23.5% of patients experiencing poor outcomes. Demographic, health, clinical, and surgery-related prognostic factors can predict ACDF outcomes. This information may further assist surgeons with patient selection and with setting realistic expectations. Future studies are needed to replicate and validate these findings prior to confident clinical implementation.

OBJECTIVE The aim of this study was to evaluate the anatomical and surgical risk factors for screw-related facet joint violation at the superior level in lumbar fusion. METHODS The authors conducted a retrospective review of a consecutive series of posterior lumbar instrumented fusions performed by a single surgeon. Inclusion criteria were primary lumbar fusion of 1 or 2 levels for degenerative disorders. The following variables were analyzed as possible risk factors: surgical technique (percutaneous vs open screw placement), depth of surgical field, degree of anterior slippage of the superior level, pedicle and facet angle, and facet degeneration of the superior level. Postoperative CT scans were evaluated by 2 independent reviewers. Axial, sagittal, and coronal views were reviewed. Pedicle screws were graded as intra-articular if they clearly interposed between the superior and inferior facet joints of the superior level. Multivariate logistic regression analyses were conducted to assess the factors associated with this complication. RESULTS One hundred thirty-one patients were included. Interobserver reliability for facet joint violation assessment was high (κ = 0.789). The incidence of superior facet joint violation was 12.59% per top-level screw (33 of 262 proximal screws). The rate of facet violation was 28.0% in the percutaneous technique group (14 of 50 patients) and 12.3% in the open surgery group (10 of 81 patients) (OR 2.26, 95% CI 1.09-4.21; p = 0.024). In multivariate logistic regression analysis, independent predictors of facet violation were percutaneous screw placement (adjusted OR 3.31, 95% CI 1.42-7.73; p = 0.006), right-side pedicle screw (adjusted OR 3.14, 95% CI 1.29-7.63; p = 0.011), and facet angle > 45° (adjusted OR 10.95, 95% CI 4.64-25.84; p < 0.0001). CONCLUSIONS The incidence of facet joint violation was higher in percutaneous minimally invasive than in open technique for posterior lumbar spine surgery. Also, coronal orientation of the facet joint is a significant risk factor independent of the surgical technique.

Study Design: Retrospective cohort study., Objective: To identify patient or procedure related predictors of postoperative blood transfusions in posterior lumbar fusion (PSF)., Summary of Background Data: The rate of PSF surgery has increased significantly. It remains the most common surgical procedure used to stabilize the spine; however, the impact of blood loss requiring blood transfusions remains a significant concern., Methods: Analysis of data from the Canadian Spine Outcomes and Research Network. Patients who underwent PSF between 2008 and 2015 were identified. Multivariate analysis was used to identify predictors of blood transfusion from the collected information., Results: Seven hundred seventy two patients have undergone PSF, 18% required blood transfusion, 54.8% were females and the mean age was 60 years. The analysis revealed five significant predictors: American Society of Anesthesiologist class (ASA), operative time, multilevel fusion, sacrum involvement, and open posterior approach. The odds of transfusion for those with ASA >1 were 6 times those with ASA1 (odds ratio [OR] 6.1, 95% confidence interval [CI] 1.4-27.1, P < 0.018). For each 60-minute increase in operative time, the odds of transfusion increased by 4.2% (OR 1.007, 95% CI 1.004-1.009, P < 0.001). The odds of transfusion were 6 times higher for multilevel fusion (OR 5.8, 95% CI 2.6-13.2, P < 0.001). Extending fusion to the sacrum showed 3 times higher odds for blood transfusion (OR 3.2, 95% CI 1.8-5.8, P < 0.001). The odds of transfusion for patients undergoing open approach were 12 times those who had minimal invasive surgery (OR 12.5, 95% CI 1.6-97.4, P < 0.016). Finally, patients receiving transfusions were more likely to have extended hospital stay., Conclusion: ASA >1, prolonged operative time, multilevel fusion, sacrum involvement, and open posterior approach were significant predictors of blood transfusion in PSF., Level of Evidence: 3.

Study Design: Retrospective cohort study., Objective: To assess the subsidence and revision rates associated with different interbody cages following anterior cervical corpectomy and reconstruction., Summary of Background Data: Different interbody cages are currently used for surgical reconstruction of the anterior and middle columns of the spine following anterior cervical corpectomy. However, subsidence and delayed union/nonunion associated with allograft and cage reconstruction are common complications, which may require revision with instrumentation., Materials and Methods: We reviewed the cases of 75 patients who underwent cervical corpectomy and compared the radiographic graft subsidence and revision rates for fibula allograft, titanium mesh cage, titanium expandable cage, and carbon fiber cages. Subsidence was calculated by comparing the immediate postoperative lateral x-ray films to those obtained during follow-up visits., Results: The average graft subsidence was 3 mm and revision rate was 25% for fibula allograft versus 2.9 mm and 11.1%, 2.9 mm and 18.8% for titanium mesh cages and titanium expandable cages, respectively. The average graft subsidence for carbon fiber cages was 0.7 mm with no revision surgery in this subset., Conclusions: Our findings suggest that subsidence and revision rates following anterior corpectomy and interbody fusion could be minimized with the use of a carbon fiber cage.

Study Design: Retrospective cohort study of the prospective collected American College of Surgeons National Surgical Quality Improvement Program database., Objective: The aim of the study was to identify predictive factors for the need of discharging patients to a facility other than home after lumbar spine fusion surgery., Summary of Background Data: Lumbar spine fusion surgery is a common surgical procedure used to treat a variety of lumbar spine conditions. A great number of patients fail to go home after surgery and require admission to a rehabilitation center. Predictive factors for discharging patients to a facility other than home after lumbar fusion surgery do not exist in the literature., Methods: A total of 15,092 patients undergoing lumbar spine fusion were dichotomized based on discharge destination to patients who were discharged home (N = 12,339) and others who were discharged to a facility other than home (N = 2753). Outcomes included patient demographics, comorbidities, and clinical characteristics. A multivariate logistic regression was used to identify whether outcomes studied were predictive factors for discharging patients to a facility other than home after lumbar fusion surgery., Results: Majority of patients were discharged home after lumbar fusion surgery (81.76%), with only some discharged to a facility other than home (18.24%). Multivariate analysis identified age, female sex, comorbidities (diabetes, chronic obstructive pulmonary disease, congestive heart failure, hypertension, and obesity), minor and major complications, hospital length of stay, operative time at least 259 minutes, and multilevel surgery as significant predictive factors of discharging patients to a facility other than home after lumbar fusion surgery., Conclusion: The identified predictive factors can help the health system in developing an algorithm for early recognition of patients requiring postoperative admission to a facility other than home and possibly decreasing their hospital length of stay. This can significantly decrease the hospital costs for such patients., Level of Evidence: 3.

Study Design: A systematic review., Objective: The purpose of this study was to review the published literature to estimate rates and identify risk factors for adjacent segment degeneration (ASDeg) and adjacent segment disease (ASDis) after lumbar fusion., Summary of Background Data: Arthrodesis remains a common intervention for the surgical treatment of degenerative spinal disease. Clinical studies have demonstrated variability in the rates of adjacent segment pathology after lumbar fusion., Methods: This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Symptoms of ASDis were distinguished and defined by the need for a revision surgery procedure to address adjacent level pathology. We searched MEDLINE, EMBASE, Cochrane Library, and CINAHL databases. Extracted data included average patient age, average time to follow-up, type of intervention, potential risk factors, and ASDeg and ASDis incidence. Funnel and forest plots were used to describe heterogeneity and meta-regression to estimate pooled incidence of ASDeg and ASDis., Results: A total of 31 articles with 4206 patients were included for analysis. Combining all extractable data, the overall pooled incidence of ASDeg was 5.9% per year (95% CI, 4.8%, 7.2%), and ASDis was 1.8% (95% CI, 1.3%, 2.4%) per year. The incidence of ASDeg is higher with more motion segments. Sex, age, segmental sagittal alignment, fusion methods, and instrumentation were not associated with an increased risk of ASDeg or ASDis. Radiographic ASDeg did not show strong correlation with clinical outcomes., Conclusions: The prevalence of ASDeg and ASDis has been variably reported in the literature, and fusion length is the factor most significantly associated with adjacent segment pathology. In guiding surgical strategies to avoid adjacent segment pathology, limiting the number of levels fused may have a greater impact than changes in fusion strategies.

Study Design: Retrospective cohort. Objectives: To compare outcomes of minimally invasive surgery (MIS) vs open surgery (OPEN) for lumbar spinal stenosis (LSS) in patients with diabetes. Methods: Patients with diabetes who underwent spinal decompression alone or with fusion for LSS within the Canadian Spine Outcomes and Research Network (CSORN) database were included. MIS vs OPEN outcomes were compared for 2 cohorts: (1) patients with diabetes who underwent decompression alone (N = 116; MIS n = 58 and OPEN n = 58), (2) patients with diabetes who underwent decompression with fusion (N = 108; MIS n = 54 and OPEN n = 54). Modified Oswestry Disability Index (mODI) and back and leg pain were compared at baseline, 6–18 weeks, and 1-year post-operation. The number of patients meeting minimum clinically important difference (MCID) or minimum pain/disability at 1-year was compared. Results: MIS approaches had less blood loss (decompression alone difference 100 mL, P =.002; with fusion difference 244 mL, P <.001) and shorter length of stay (LOS) (decompression alone difference 1.2 days, P =.008; with fusion difference 1.2 days, P =.026). MIS compared to OPEN decompression with fusion had less patients experiencing adverse events (AEs) (difference 13 patients, P =.007). The MIS decompression with fusion group had lower 1-year mODI (difference 14.5, 95% CI [7.5, 21.0], P <.001) and back pain (difference 1.6, 95% CI [.6, 2.7], P =.002) compared to OPEN. More patients in the MIS decompression with fusion group exceeded MCID at 1-year for mODI (MIS 75.9% vs OPEN 53.7%, P =.028) and back pain (MIS 85.2% vs OPEN 70.4%, P =.017). Conclusions: MIS approaches were associated with more favorable outcomes for patients with diabetes undergoing decompression with fusion for LSS. [ABSTRACT FROM AUTHOR]