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Study Design: Retrospective cohort study. Objectives: The coronavirus disease (COVID-19), caused by the severe respiratory syndrome coronavirus 2 (SARS-CoV-2), has created an unprecedented global public health emergency. The aim of the current study was to report on COVID-19 rates in an asymptomatic population prior to undergoing spine procedures or surgeries at two large Los Angeles healthcare systems. Methods: Elective spine procedures and surgeries from May 1, 2020 to January 31, 2021 were included. Results from SARS-CoV-2 virus RT-PCR nasopharyngeal testing within 72 hours prior to elective spine procedures were recorded. Los Angeles County COVID-19 rates were calculated using data sets from Los Angeles County Department of Public Health. Chi-squared test and Stata/IC were used for statistical analysis. Results: A total of 4,062 spine procedures and surgeries were scheduled during this time period. Of these, 4,043 procedures and surgeries were performed, with a total of 19 patients testing positive. Nine positive patients were from UCLA, and 10 from USC. The overall rate of positive tests was low at.47% and reflected similarities with Los Angeles County COVID-19 rates over time. Conclusions: The current study shows that pre-procedure COVID-19 testing rates remains very low, and follows similar patterns of community rates. While pre-procedure testing increases the safety of elective procedures, universal COVID-19 pre-screening adds an additional barrier to receiving care for patients and increases cost of delivering care. A combination of pre-screening, pre-procedure self-quarantine, and consideration of overall community COVID-19 positivity rates should be further studied. [ABSTRACT FROM AUTHOR]

Purpose: Current decision-making in multilevel cervical fusion weighs the potential to protect adjacent levels and reduce reoperation risk by crossing the cervicothoracic junction (C7/T1) against increased operative time and risk of complication. Careful planning is required, and the planned distal and adjacent levels should be assessed for degenerative disc disease (DDD). This study assessed whether DDD at the cervicothoracic junction was associated with DDD, disc height, translational motion, or angular variation in the adjacent superior (C6/C7) or inferior (T1/T2) levels. Methods: This study retrospectively analyzed 93 cases with kinematic MRI. Cases were randomly selected from a database with inclusion criteria being no prior spine surgery and images having sufficient quality for analysis. DDD was assessed using Pfirrmann classification. Vertebral body bone marrow lesions were assessed using Modic changes. Disc height was measured at the mid-disc in neutral and extension. Translational motion and angular variation were calculated by assessing translational or angular motion segment integrity respectively in flexion and extension. Statistical associations were assessed with scatterplots and Kendall's tau. Results: DDD at C7/T1 was positively associated with DDD at C6/C7 (tau = 0.53, p < 0.01) and T1/T2 (tau = 0.58, p < 0.01), with greater disc height in neutral position at T1/T2 (tau = 0.22, p < 0.01), and with greater disc height in extended position at C7/T1 (tau = 0.17, p = 0.04) and at T1/T2 (tau = 0.21, p < 0.01). DDD at C7/T1 was negatively associated with angular variation at C6/C7 (tau = − 0.23, p < 0.01). No association was appreciated between DDD at C7/T1 and translational motion. Conclusion: The association of DDD at the cervicothoracic junction with DDD at the adjacent levels emphasizes the necessity for careful selection of the distal level in multilevel fusion in the distal cervical spine. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective cohort study. Objectives: The impact of modifiable risk factors (MRFs) on complications, costs, and readmission rates at 30, 90, and 180-days following lumbar spine fusion. Methods: Patients with lumbar spine fusions within the 2016-2017 Nationwide Readmissions Database (NRD). Patients were stratified by the following MRFs: Alcohol use, tobacco/nicotine use, nutritional malnourishment, dyslipidemia, and primary hypertension. Differences in complications, non-elective readmission rates, costs, and length of stay were compared between MRFs and the non-MRF group. Statistical analysis was conducted using Tukey multiple comparisons of means, 1-way ANOVA, Wald testing, unpaired Welch 2-sample t-tests, multivariate analysis, and predictive modeling. Results: The final analysis included 297,579 lumbar fusion patients. At 30 and 90 days, patients with nutritional malnutrition, dyslipidemia, and primary hypertension had significantly greater readmission rates than patients without MRFs (all P < 0.01). At 180-days, all MRFs had significantly greater readmission rates than the non-MRF group (all P < 0.001). Dyslipidemia demonstrated significantly greater rates of myocardial infarction at 90 days compared to all groups (all P < 0.02). Nutritional malnutrition was associated with a significantly greater mortality rate than primary hypertension, non-MRF, and tobacco/nicotine use at 90 days (P <0.001) and only tobacco/nicotine use at 180 days (P =0.007). Predictive modeling showed increases of 0.77%, 1.70%, and 2.44% risk of readmission at 30, 90, and 180-days respectively per additional MRF (all P <0.001). Conclusions: These findings highlight the negative impact each MRF has on patients following lumbar spinal fusion. Further longitudinal research is necessary to comprehensively characterize the effects of various MRFs on spine surgery outcomes. [ABSTRACT FROM AUTHOR]

Purpose: To describe the incidence of complications associated with cervical spine surgery and post-operative physical therapy (PT), and to identify if the timing of initiation of post-operative PT impacts the incidence rates. Methods: MOrtho PearlDiver database was queried using billing codes to identify patients who had undergone Anterior Cervical Discectomy and Fusion (ACDF), Posterior Cervical Fusion (PCF), or Cervical Foraminotomy and post-operative PT from 2010–2019. For each surgical procedure, patients were divided into three 12-week increments for post-operative PT (starting at post-operative weeks 2, 8, 12) and then matched based upon age, gender, and Charlson Comorbidity Index score. Each group was queried to determine complication rates and chi-square analysis with adjusted odds ratios, 95% confidence intervals, and p-values were used. Results: Following matching, 3,609 patients who underwent cervical spine surgery at one or more levels and had post-operative PT (ACDF:1784, PCF:1593, and cervical foraminotomy:232). The most frequent complications were new onset cervicalgia (2–14 weeks, 8–20 weeks, 12–24 weeks): ACDF (15.0%, 14.0%, 13.0%), PCF (18.8%, 18.0%, 19.9%), cervical foraminotomy (16.8%, 16.4%, 19.4%); revision: ADCF (7.9%, 8.2%, 7.4%), PCF (9.3%, 10.6%, 10.2%), cervical foraminotomy (11.6%, 10.8% and 13.4%); wound infection: ACDF (3.3%, 3.4%, 3.1%), PCF (8.3%, 8.0%,7.7%), cervical foraminotomy (5.2%, 6.5%, < 4.7%). None of the comparisons were statistically significant. Conclusion: The most common post-operative complications included new onset cervicalgia, revision and wound infection. Complications rates were not impacted by the timing of initiation of PT whether at 2, 8, or 12 weeks post-operatively. [ABSTRACT FROM AUTHOR]

Purpose: Lumbar fusion is widely used to treat degenerative and traumatic conditions of the spine, with various perioperative complications. This study compared lumbar fusion complications in patients with and without chronic hyperlipidemia.Methods: Using the MSpine division of the PearlDiver database, patients with or without chronic hyperlipidemia who underwent lumbar fusions were identified. The appropriate Current Procedural Terminology (CPT) codes identified patients with single- or multi-level lumbar spinal fusion surgeries. International Classification of Diseases (ICD-9 and ICD-10) codes identified patients with chronic hyperlipidemia. The surgical and medical complications were obtained utilizing the appropriate ICD-9, ICD-10, and CPT codes. Propensity score matching analysis was used to control for confounding factors. Chi-square test was applied to compare the incidence of complications among different groups.Results: In single-level fusion group, patients with hyperlipidemia had a higher incidence of wound complications (P < 0.001), surgical site infection (P < 0.001), failed back syndrome (P < 0.001), hardware removal (P < 0.001), deep venous thrombosis/pulmonary embolism (P = 0.031), myocardial infarction (P < 0.001) cerebrovascular accident (P < 0.001), renal failure (P < 0.001), sepsis (P < 0.001), and urinary tract infection/incontinence (P < 0.001). In multi-level fusion group, patients with hyperlipidemia had a higher incidence of nerve root injury (P = 0.034), wound complications (P < 0.001), surgical site infection (P < 0.001), failed back syndrome (P < 0.001), hardware removal (P < 0.001), revision (P = 0.002), myocardial infarction (P < 0.001), renal failure (P < 0.001), and urinary tract infection/incontinence (P < 0.001).Conclusion: Following lumbar fusion, patients with chronic hyperlipidemia have an increased risk of perioperative complications, including wound complications, surgical site infection, failed back surgery syndrome, hardware removal, myocardial infarction, renal failure, and urinary tract infection/incontinence. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the use of guidelines for lumbar spine fusions among spine surgeons in North America. Methods: An anonymous survey was electronically sent to all AO Spine North America members. Survey respondents were asked to indicate their opinion surrounding the suitability of instrumented fusion in a variety of clinical scenarios. Fusion indications in accordance with North America Spine Society (NASS) guidelines for lumbar fusion were considered NASS-concordant answers. Respondents were considered to have a NASS-concordant approach if ≥ 70% (13 of 18) of their answers were NASS-concordant answers. Comparisons were performed using bivariable statistics. Results: A total of 105 responses were entered with complete data available on 70. Sixty percent of the respondents (n = 42) were considered compliant with NASS guidelines. NASS-discordant responses did not differ between surgeons who stated that they include the NASS guidelines in their decision-making algorithm (5.10 ± 1.96) and those that did not (4.68 ± 2.09) (p = 0.395). The greatest number of NASS-discordant answers in the United States. was in the South (5.75 ± 2.09), with the lowest number in the Northeast (3.84 ± 1.70) (p < 0.01). For 5 survey items, rates of NASS-discordant answers were ≥ 40%, with the greatest number of NASS-discordant responses observed in relation to indications for fusion in spinal deformity (80%). Spine surgeons utilizing a NASS-concordant approach had a significant lower number of NASS-discordant answers for synovial cysts (p = 0.03), axial low back pain (p < 0.01), adjacent level disease (p < 0.01), recurrent stenosis (p < 0.01), recurrent disc herniation (p = 0.01), and foraminal stenosis (p < 0.01). Conclusion: This study serves an important role in clarifying the rates of uptake of clinical practice guidelines in spine surgery as well as to identify barriers to their implementation. [ABSTRACT FROM AUTHOR]

Purpose: To elucidate the effects of bisphosphonates on complications following posterior lumbar fusion (PLF) with a large database study. Methods: 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. Results: 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. Conclusion: 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. [ABSTRACT FROM AUTHOR]

Study Design: Methodological study for guideline development. Objective: AO Spine Guideline for Using Osteobiologics (AO-GO) project for spine degenerative pathologies was an international, multidisciplinary collaborative initiative to identify and evaluate evidence on existing use of osteobiologics in Anterior Cervical Fusion and Decompression (ACDF). The aim was to formulate precisely defined, clinically relevant and internationally applicable guidelines ensuring evidence-based, safe and effective use of osteobiologics, considering regional preferences and cost-effectiveness. Methods: Guideline was completed in two phases: Phase 1- evidence synthesis; Phase 2- recommendation development based on the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. In Phase 1, key questions identified by a panel of experts were addressed in a series of systematic reviews of randomized and non-randomized studies. In Phase 2, the GRADE approach was used to formulate a series of recommendations, including expert panel discussions via web calls and face-to-face meetings. Discussion: AO-GO aims to bridge an important gap between evidence and use of osteobiologics in spine fusion surgeries. Owing to differences in osteobiologics preparation and functional characteristics, regulatory requirements for approval may vary, therefore it is highly likely that these products enter market without quality clinical trials. With a holistic approach the guideline aims to facilitate evidence-based, patient-oriented decision-making processes in clinical practice, thus stimulating further evidence-based studies regarding osteobiologics usage in spine surgeries. In Phase 3, the guideline will be disseminated and validated using prospectively collected clinical data in a separate effort of the AO Spine Knowledge Forum Degenerative in a global multicenter clinical study. [ABSTRACT FROM AUTHOR]

Study Design: Systematic literature review Objective: To critically analyze the literature and describe the complications associated with the use of allograft in 1- or 2- level anterior cervical discectomy and fusion (ACDF) Methods: A systematic search of PubMed/MEDLINE, EMBASE, and ClinicalTrials.gov databases was conducted for literature published between January 2000 and August 2020 reporting complications associated with the use of allograft in 1- or 2- level ACDF. Results: From 584 potentially relevant citations, 21 met the inclusion criteria (4 randomized controlled trials (RCT), 4 prospective, and 13 retrospective studies). The patient number varied between 26 and 463 in comparative studies (RCT and non-RCT) and between 29 and 345 in non-comparative studies. Fusion rate was reported in 14 studies and ranged between 68.5-100%. The most frequently reported complication was post-operative dysphagia or dysphonia, with incidences ranging between.5% and 14.4%. Revision surgery was the second most reported complication (14 studies) and ranged between 0% and 10.3%. Wound-related complications were reported in 6 studies and ranged between 0% and 22.8%. Conclusion: The overall reporting of complications was low with very few comparative studies. Reported complications with allografts are within the range of other osteobiologics and autografts and in most cases may not attributable to the use of osteobiologics and may be complications of the procedure itself. Comparative studies with a more robust methodology analyzing complications with allograft and other osteobiologics are needed to inform current practice with strong recommendations. [ABSTRACT FROM AUTHOR]

Study Design: Network meta-analysis. Objectives: To compare the fusion outcome and complications of different 1 or 2-level anterior cervical decompression and fusion (ACDF) constructs performed with and without the application of autografts. Methods: We performed an independent and duplicate search in electronic databases including PubMed, Embase, Web of Science, Cochrane, and Scopus for relevant articles published between 2000 and 2020. We included comparative studies reporting fusion rate and complications with and without the use of autografts in ACDF across 5 different fusion constructs. A network meta-analysis was performed in Stata, categorized based on the type of fusion constructs utilized. Fusion constructs were ranked based on p-score approach and surface under cumulative ranking curve (SUCRA) scores. The confidence of results from the analysis was appraised with Cochrane's CINeMA approach. Results: A total of 2216 patients from 22-studies including 6 Randomized Controlled Trials (RCTs) and 16 non-RCTs were included in network analysis. The mean age of included patients was 49.3 (±3.62) years. Based on our meta-analysis, we could conclude that use of autograft in 1- or 2-level ACDF did not affect the fusion and mechanical implant-related complications. The final fusion and mechanical complication rates were also not significantly different across the different fusion constructs. The use of plated constructs was associated with a significant increase in post-ACDF dysphagia rates [OR 3.42; 95%CI (.01,2.45)], as compared to stand-alone constructs analysed. Conclusion: The choice of fusion constructs and use of autografts does not significantly affect the fusion and overall complication rates following 1 or 2-level ACDF surgery. [ABSTRACT FROM AUTHOR]

Study Design: Systematic Review and Meta-Analysis. Objectives: To compare complication incidence in patients with or without the use of recombinant human Bone Morphogenic Protein-2 (BMP2) undergoing anterior cervical discectomy and fusion (ACDF) for degenerative conditions. Methods: A systematic search of eight online databases was conducted using PRISMA guidelines. Inclusion criteria included English language studies with a minimum of 10 adult patients undergoing instrumented ACDF surgery for a degenerative spinal condition in which BMP2 was used in all patients or one of the treatment arms. Studies with patients undergoing circumferential fusions, with non-degenerative indications, or which did not report post-operative complication data were excluded. Patients with and without BMP2 were compared in terms of the incidence of dysphagia/dysphonia, anterior soft tissue complications (hematoma, seroma, infection, dysphagia/dysphonia), nonunion, medical complications, and new neurologic deficits. Results: Of 1832 preliminary search results, 27 manuscripts were included. Meta-analysis revealed the relative risk of dysphagia or dysphonia (RR = 1.39, CI 95% 1.18 – 1.64, P = <.001), anterior soft tissue complications (RR = 1.43, CI 95% 1.25-1.64, P = <.001), and medical complications (RR = 1.32, CI 95% 1.06-1.66, P =.013) were statistically significant in the BMP2 group while the relative risk of non-union (RR =.5, CI 95%.23 - 1.13, P =.09) trended lower in the BMP2 group. Neurological deficit (RR = 1.06, CI 95%.82-1.37, P =.66), and additional medical complications (RR = 1.53, CI 95%.98-2.38, P =.06) were not found to be statistically different between the groups. Conclusions: This meta-analysis identified a high rate of arthrodesis when BMP2 was used in ACDF, but confirmed increased rates of dysphagia and anterior soft tissue complications. Surgeons may consider reserving BMP2 implementation for cases with a high risk of non-union, and should be aware of the risk of airway compromise. [ABSTRACT FROM AUTHOR]

Background: Despite the extensive use of cellular bone matrices (CBMs) in spine surgery, there is little evidence to support the contribution of cells within CBMs to bone formation. The objective of this study was to determine the contribution of cells to spinal fusion by direct comparisons among viable CBMs, devitalized CBMs, and cell-free demineralized bone matrix (DBM).Methods: Three commercially available grafts were tested: a CBM containing particulate DBM (CBM-particulate), a CBM containing DBM fibers (CBM-fiber), and a cell-free product with DBM fibers only (DBM-fiber). CBMs were used in viable states (CBM-particulatev and CBM-fiberv) and devitalized (lyophilized) states (CBM-particulated and CBM-fiberd), resulting in 5 groups. Viable cell counts and bone morphogenetic protein-2 (BMP-2) content on enzyme-linked immunosorbent assay (ELISA) within each graft material were measured. A single-level posterolateral lumbar fusion was performed on 45 athymic rats with 3 lots of each product implanted into 9 animals per group. After 6 weeks, fusion was assessed using manual palpation, micro-computed tomography (μ-CT), and histological analysis.Results: The 2 groups with viable cells were comparable with respect to cell counts, and pairwise comparisons showed no significant differences in BMP-2 content across the 5 groups. Manual palpation demonstrated fusion rates of 9 of 9 in the DBM-fiber specimens, 9 of 9 in the CBM-fiberd specimens, 8 of 9 in the CBM-fiberv specimens, and 0 of 9 in both CBM-particulate groups. The μ-CT maturity grade was significantly higher in the DBM-fiber group (2.78 ± 0.55) compared with the other groups (p < 0.0001), while none of the CBM-particulate samples demonstrated intertransverse fusion in qualitative assessments. The viable and devitalized samples in each CBM group were comparable with regard to fusion rates, bone volume fraction, μ-CT maturity grade, and histological features.Conclusions: The cellular component of 2 commercially available CBMs yielded no additional benefits in terms of spinal fusion. Meanwhile, the groups with a fiber-based DBM demonstrated significantly higher fusion outcomes compared with the CBM groups with particulate DBM, indicating that the DBM component is probably the key determinant of fusion.Clinical Relevance: Data from the current study demonstrate that cells yielded no additional benefit in spinal fusion and emphasize the need for well-designed clinical studies on cellular graft materials. [ABSTRACT FROM AUTHOR]

Purpose: 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.Methods: 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.Results: 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).Conclusion: 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. [ABSTRACT FROM AUTHOR]

Purpose: Although the T1 vertebra is considered as an important factor of cervical balance, little is known about its motion between flexion and extension. The purpose of present study was to analyze the T1 sagittal motion using kinematic magnetic resonance imaging (kMRI), and to identify factors that relate to T1 sagittal motion.Methods: We retrospectively analyzed 145 kMR images taken in weight-bearing neutral, flexion and extension positions. Cervical balance parameters were evaluated in each position. The degree of T1 sagittal motion was defined as [(T1 slope at extension) - (T1 slope at flexion)]. All patients were divided into three groups: Positive group (T1 followed the head motion, T1 sagittal motion > 5°), Stable group (5 ≥, ≥ - 5) and Negative group (T1 moved in the opposite direction from the head motion, > - 5). The groups were compared and multivariate logistic regression analysis was calculated.Results: There were 57 (40%) patients in the positive, 56 (39%) in the stable and 32 (22%) in the negative group. The positive group had the largest C2-7 sagittal vertical axis in flexion (p < 0.001) and the shortest in the extension (p = 0.023). Similar trends were seen in cranial tilt and cervical tilt. The value of T1 height < 27 mm was a significant independent factor for the negative group (p = 0.008, adjusted odds ratio = 5.958).Conclusion: Based on T1 sagittal motion, 40% of the patients were classified in positive group (the T1 vertebra followed the head motion in flexion and extension), and 20% were classified in the negative group (the T1 vertebra moved in the opposite direction from the head motion). T1 height < 27 mm was a potential predictor of negative group. [ABSTRACT FROM AUTHOR]

Purpose: To test the reliability and validity of the multi-positional magnetic resonance imaging (MRI) in measuring cervical angular parameter using the standard dynamic cervical X-ray as a reference.Methods: All patients who underwent both cervical dynamic plain radiograph and multi-positional MRI on the same day between 2010 and 2016 were included in this study. The C2-7 angle and the segmental angles of the C2-3 to C6-7 segments were measured in all three positions (neutral, flexion, and extension) using multi-positional MRI and dynamic radiograph. The Pearson's correlation coefficients and linear regression analysis were used for statistical analysis.Results: 46 patients were enrolled in this study. All angular parameters showed significant positive correlation between multi-positional MRI and dynamic X-ray (p < 0.05). The angle of C2-7 showed significantly positive correlation between multi-positional MRI and X-ray (r = 0.552-0.756). All segmental angles from C2-3 to C6-7 showed moderate correlation (r = 0.401-0.636). The linear regression analysis showed that C2-7 angles and all angular parameters had significant correlation between multi-positional MRI and dynamic X-ray (p < 0.05, R 2 = 0.107-0.571).Conclusions: The C2-7 angle and segmental cervical angles measured by multi-positional MRI were valid, and reliability substituted the dynamic X-ray measurement within the acceptable range of error. Multi-positional MRI can be used as a reliable tool for angular parameter measurement and detection of angular instability in the cervical spine. [ABSTRACT FROM AUTHOR]

Purpose: The aim of our study was to investigate the trends and incidence of vertebral augmentation procedures (VAPs) in treating osteoporotic vertebral compression fractures. Results: In total, 118,074 patients were analyzed. The overall incidence of VAPs was 15.2%. The incidence of VAPs was significantly higher in those 75-79 years old (20.4%), significantly higher in females than males (15.6% versus 14.9%), and most commonly performed in the South (17.7%). Conclusion: There was a decline in the frequency of these procedures since 2008, but physicians are still performing these procedures, albeit at a much lower frequency than before 2009. [ABSTRACT FROM AUTHOR]

However, given that 664 patients in our study were identified with myocardial infarction and were further stratified based on the approach and timing, the propensity matching was not possible. We believe that information of the surgical approach and timing of myocardial infarction after lumbar surgery is novel and important information. [Extracted from the article]

Anterior cervical discectomy and fusion (ACDF) is a treatment for degenerative spine conditions when symptoms become refractory to conservative management. While pain and neurological function often improve after ACDF, some patients continue to have persistent pain and disability which can benefit from postoperative physical therapy (PT). With the potential advent of bundled payments in spine surgery, it is necessary to determine if the use of postoperative PT is cost-effective. To analyze the health care utilization associated with patients who underwent 1-2 level ACDF alone compared to those who underwent ACDF and postoperative PT. Retrospective database study. Patients who underwent 1,2-level ACDF for degenerative cervical pathologies from 2010-2021 (n=355,188) either with or without postoperative physical therapy. Health care utilization (advanced imaging, revisions, opioid use). PearlDiver database was used to identify patients who underwent 1,2-level ACDF for degenerative cervical spine disorders without or with postoperative PT from 2010-2021. Demographic and procedural data was obtained using International Classification of Disease 9th and 10th Revision (ICD-9, ICD-10) and Current Procedural Terminology (CPT) codes. Postoperative PT included active and passive PT CPT codes. Both Non-PT and PT groups were 1:1 propensity-matched for age, sex, and Elixhauser Comorbidity Index (ECI) scores. Health care utilization included revision surgery, opioid use, and advanced imaging. Advanced imaging was defined by computer tomography (CT) and/or magnetic resonance imaging (MRI) of the cervical spine. Chi-squared analysis, and independent t-test were performed to assess differences in health care utilization, between non-PT and PT subgroups at 2-, 6-, and 12 weeks postoperatively. A total of 355,188 patients underwent 1,2-level ACDF (n=215,764 no PT, n=139,424 with postoperative PT). PT cohort had significantly greater proportions of female patients (57.7% vs 53.5%, p<0.001), myelopathy (26.2% vs 23.3%; p<0.001) and preoperative opioid use (50.5% vs 48.8%; p<0.001). Non-PT cohort had higher proportions of obesity (9.7% vs 8.5%; p<0.001), smoking (21% vs 19.4%; p<0.001), and depression (13% vs 11.9%; p<0.001). Postoperative PT initiated at 2 weeks was associated with significantly more advanced imaging at 3,6 months (p=.012) and 30-day opioid use.(p=.047) and significantly less revisions (p=0.007) and opioid use at 18 months (p=.031); PT at 6 weeks was associated with significantly more advanced imaging at 3,6, 18 months (p<0.001, p=.008) and opioid use at 30 days, 3 months (p<0.001, p=.004) and significantly less opioid use at 9 months (p,.001); PT at 12 weeks was associated with significantly more advanced imaging at 30 days, 3-, 6-,18 months (p=.002, p<0.001) and opioid use at 30 days, 3 months (p<0.001, p=.032) although significantly less opioid use at 9 months (p=.011). No significant difference for other time points and groups. The benefits of postoperative PT for ACDF become more appreciable in the long-term for revisions and postoperative opioid use despite higher proportions of myelopathy and preoperative opioid use. Revision rates in the short-term were not significantly different between non- PT/PT cohorts. Advance imaging appears to be utilized significantly more when initiating postoperative PT at 6,12 weeks vs 2 weeks or no PT. Postoperative PT may aid in long term opioid usage after 1-2 level ACDF surgeries and may be initiated as early as 2 weeks without increased rate of revision surgery. Future prospective RCTs are needed to determine association of these findings with patient reported outcomes, return to work and quality of life. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Study Design.: Retrospective cross-sectional review of a large database Objective.: Little is known regarding extension K-lines for treatment of cervical myelopathy. Therefore, this study seeks to examine differences between K-lines drawn in neutral and extension. Summary of Background Data.: The modified K-line is a radiological tool used in surgical planning of the cervical spine. As posterior cervical decompression and fusion often results in patients being fused in a more lordotic position than the preoperative neutral radiograph, a K-line measured in the extension position may offer better utility for these patients. Materials and Methods.: Total of 97 patients were selected with T2-weighted, upright cervical magnetic resonance imaging taken in neutral and extension. For each patient, the K-line was drawn at the mid-sagittal position for both neutral and extension. The distance from the most posterior portion of each disk (between C2 and C7) to the K-line was measured in neutral and extension and the difference was calculated. Paired t test was used to assess significant differences. Results.: Across all levels between C2 and C7 there was an increase in the distance between the dorsal aspect of the disk and K-line when comparing neutral and extension radiographs. The average change in difference (extension minus neutral) at each cervical spinal level was 0.9 mm (C2–C3), 2.5 mm (C3–C4), 2.6 mm (C4–C5), 2.0 mm (C5–C6), and 0.9 mm (C6–C7). A paired t test showed that the K-line increase from neutral to extension was statistically significant across all disk levels (P <0.001). Conclusion.: When positioned in extension, patients experience a significant increase in distance from the dorsal aspect of a disk to the K-line compared to when positioned in neutral, especially between C3 and C6. This is clinically relevant for surgeons considering a posterior cervical decompression and fusion in patients with a negative modified K-line on preoperative magnetic resonance imaging, as these patients may have enough cervical cord drift back when fused in an extended position, maximizing likelihood of improving postoperative DSM functional outcomes. [ABSTRACT FROM AUTHOR]

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. 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. Retrospective Cohort Study. A total of 7,772 patients underwent spinal fusion with spinal metastasis within the Nationwide Readmissions Database (NRD). Mortality, medical complications, surgical complications, increased length of stay (LOS), nonroutine discharge and increased costs. 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). 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. 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. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Parkinson disease (PD) is a risk factor for worse surgical outcomes. The degree to which PD affects outcomes in cervical spine surgery is not well understood. Therefore, we characterize rates of postoperative complications among patients with PD who undergo cervical spine surgery. Using the PearlDiver database, we identified patients who underwent 1-level anterior cervical discectomy and fusion (ACDF), posterior cervical fusion (PCF), or discectomy/decompression with concomitant PD between 2011 and 2019. Patients with PD who underwent surgery and had 1 year follow-up were included. Complications 30, 60, and 90 days after surgery were identified and aggregated into body systems (e.g., respiratory and gastrointestinal). Comparison controls without concomitant PD who received cervical spine (C-spine) surgery were matched for age, sex, and comorbidities. A total of 259,443 ACDFs, 30,929 PCFs, and 29,563 decompressions were identified. Of these procedures, 1117 were performed on patients with PD (0.35%). The highest 90-day complications rates in patients with PD were pulmonary and gastrointestinal related (6.05%) in those who received ACDF, neuro related (8.51%) in those who received PCF, and genitourinary related (8.76%) in those who received a decompression. Compared with patients without PD, postoperative complications rates were similar and not significantly different. Patients with PD who receive ACDF have higher rates of pulmonary (6.05%), neurologic (5.24%), and psychiatric (3.23%) complications at 90 days. The differences did not reach statistical significance. This finding suggests that patients with PD do not experience higher rates of acute postoperative complications when undergoing 1-level cervical spine surgery. [ABSTRACT FROM AUTHOR]

Background Context: Adjacent segment disease (ASD) is a potential complication following lumbar spinal fusion.Purpose: This study aimed to demonstrate the demographic, clinical, and operative risk factors associated with ASD development following lumbar fusion.Study Design/setting: Systematic review and meta-analysis.Patient Sample: We identified 35 studies that reported risk factors for ASD, with a total number of 7,374 patients who had lumbar spine fusion.Outcome Measures: We investigated the demographic, clinical, and operative risk factors for ASD after lumbar fusion.Methods: A literature search was done using PubMed, Embase, Medline, Scopus, and the Cochrane library databases from inception to December 2019. The methodological index for non-randomized studies (MINORS) criteria was used to assess the methodological quality of the included studies. A meta-analysis was done to calculate the odds ratio (OR) with the 95% confidence interval (CI) for dichotomous data and mean difference (MD) with 95% CI for continuous data.Results: Thirty-five studies were included in the qualitative analysis, and 22 studies were included in the meta-analyses. The mean quality score based on the MINORS criteria was 12.4±1.9 (range, 8-16) points. Significant risk factors included higher preoperative body mass index (BMI) (mean difference [MD]=1.97 kg/m2; 95% confidence interval [CI]=1.49-2.45; p<.001), floating fusion (Odds ratio [OR]=1.78; 95% CI=1.32-2.41; p<.001), superior facet joint violation (OR=10.43; 95% CI=6.4-17.01; p<.001), and decompression outside fusion construct (OR=1.72; 95% CI=1.25-2.37; p<.001).Conclusions: The overall level of evidence was low to very low. Higher preoperative BMI, floating fusion, superior facet joint violation, and decompression outside fusion construct are significant risk factors of development of ASD following lumbar fusion surgeries. [ABSTRACT FROM AUTHOR]

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 (P < 0.05). In addition, frail patients were more often discharged to skilled nursing facilities and short-term hospitals compared with nonfrail patients (P < 0.0001). 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. [ABSTRACT FROM AUTHOR]

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<0.0001), wound dehiscence (OR: 3.76, 95% CI: 2.08-7.51, P<0.0001), 30-day readmission (OR: 1.62, 95% CI: 1.36-1.93, P<0.0001), and 90-day readmission (OR: 1.53, 95% CI: 1.31-1.79, P<0.0001) compared with controls. Predictive modeling showed cumulative increases of 6.44% in infection, 3.69% in wound dehiscence, and 1.35% in readmission within 90-days for each successive BMI cohort. Conclusion. Progressively higher risks for infection, wound complications, and hospital readmission were found with each progressive BMI level. [ABSTRACT FROM AUTHOR]

Background Context: Previous studies have found an association between mental illness and poor outcomes in spine surgery, but little is known about the effects of depression and/or anxiety on the adult spinal deformity population. In addition, most relevant studies exclusively focused on the lumbar spine and had relatively small patient sizes.Purpose: The aim of this study was to investigate whether adult spinal deformity patients with depression and/or anxiety have an increased risk of postoperative complications and reoperation following posterior thoracolumbar spinal surgery.Study Design/setting: Retrospective database study.Methods: Adult patients (over 18 years of age) with a diagnosis of spinal deformity undergoing any reconstructive thoracic or thoracolumbar spinal procedure with a posterior approach between 2007 and 2015 Q2 were identified using Current Procedural Terminology codes to query the Pearl Diver patient record database (Pearl Diver Technologies, West Conshohocken, PA, USA). The database includes records of approximately 18 million patients across the United States having Humana insurance. Further selection of patients with depression and/or anxiety and their associated postoperative complications were identified using ICD-9 and ICD-10 diagnosis codes (International Classification of Diseases 9th-10th edition). The mental illness cohort was matched to a control group according to age, sex, and Charlson Comorbidity Index. Patient data was analyzed for reoperation rates and incidence of common postoperative complications.Results: Multilevel posterolateral fusion was the most common included posterior thoracic reconstructive surgery. The mental illness cohort (n = 327) had significantly increased rates of infection (odds ratio [OR] = 1.743, p = .022) and respiratory complications (OR = 1.492, p = .02) at the 90-day postoperative period. The rates of incision and drainage (OR = 1.379, p = .475) and pneumonia (OR = 1.22, p = .573) were increased in the mental illness cohort at the 90-day postoperative period, but not significantly. There were no significant differences in complication and reoperation rates at 1-year postoperatively.Conclusions: Patients with spinal deformity and pre-existing depression and/or anxiety treated with a posterior thoracolumbar reconstructive spinal surgery had significantly elevated risk of postoperative infections and respiratory complications when compared with the control group. [ABSTRACT FROM AUTHOR]

Background Context: With the changing landscape of health care, outpatient spine surgery is being more commonly performed to reduce cost and to improve efficiency. Anterior cervical discectomy and fusion (ACDF) is one of the most common spine surgeries performed and demand is expected to increase with an aging population.Purpose: The objective of this study was to determine the nationwide trends and relative complication rates associated with outpatient ACDF.Study Design/setting: This is a large-scale retrospective case control study.Patient Sample: The patient sample included Humana-insured patients who underwent one- to two-level ACDF as either outpatients or inpatients from 2011 to 2016 OUTCOME MEASURES: The outcome measures included incidence and the adjusted odds ratio (OR) of postoperative medical and surgical complications within 1 year of the index surgery.Materials and Methods: A retrospective review was performed of the PearlDiver Humana insurance records database to identify patients undergoing one- to two-level ACDF (Current Procedural Terminology [CPT]-22551 and International Classification of Diseases [ICD]-9-816.2) as either outpatients or inpatients from 2011 to 2016. The incidence of perioperative medical and surgical complications was determined by querying for relevant ICD and CPT codes. Multivariate logistic regression adjusting for age, gender, and Charlson Comorbidity Index was used to calculate ORs of complications among outpatients relative to inpatients undergoing ACDF.Results: Cohorts of 1,215 patients who underwent outpatient ACDF and 10,964 patients who underwent inpatient ACDF were identified. The median age was in the 65-69 age group for both cohorts. The annual relative incidence of outpatient ACDF increased from 0.11 in 2011 to 0.22 in 2016 (R2=0.82, p=.04). Adjusting for age, gender, and comorbidities, patients undergoing outpatient ACDF were more likely to undergo revision surgery for posterior fusion at both 6 months (OR 1.58, confidence interval [CI] 1.27-1.96, p<.001) and 1 year (OR 1.79, CI 1.51-2.13, p<.001) postoperatively. Outpatient ACDF was also associated with a higher likelihood of revision anterior fusion at 1 year postoperatively (OR 1.46, CI 1.26-1.70, p<.001). Among medical complications, postoperative acute renal failure was more frequently associated with outpatient ACDF than inpatient ACDF (OR 1.25, CI 1.06-1.49, p=.010). Adjusted rates of all other queried surgical and medical complications were comparable.Conclusions: Outpatient ACDF is increasing in frequency nationwide over the past several years. Nationwide data demonstrate a greater risk of perioperative surgical complications, including revision anterior and posterior fusion, as well as a higher risk of postoperative acute renal failure. Candidates for outpatient ACDF should be counseled and carefully selected to reduce these risks. [ABSTRACT FROM AUTHOR]

Several studies have shown that factors such as insurance type and patient income are associated with different readmission rates following certain orthopaedic procedures. The present study evaluates 30-day complication and readmission rates as a function of hospital type, insurance type, and patient median income in patients undergoing lumbar spine fusion. Retrospective cohort analysis Using the National Readmissions Database (NRD), we identified patients who underwent a primary lumbar spine fusion from 2010-2016. Primary outcome measures were 30-day readmission and complication rates. Complications of interest were infection, wound injury, hematoma, neurological injury, thromboembolic event, and hardware failure. International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) codes were used to identify 596,568 patients who underwent a primary lumbar spine fusion from 2010-2016. Three separate analyses were performed using hospital type, insurance type, and patient income quartile as independent variables. Hospital type included the following groups: metropolitan non-teaching (n=212,131), metropolitan teaching (n=364,752), and rural (n=19,685). Insurance type was divided into 4 groups: Medicare (n=213,534), Medicaid (n=78,520), private insurance (n=196,648), and out-of-pocket payers (n=45,025). Income quartiles included Quartiles 1 (n=112,083), 2 (n=145,755), 3 (n=156,276), and 4 (n=147,289), with Quartile 1 corresponding to the poorest populations and Quartile 4 to the wealthiest populations. Nonparametric Kruskal-Wallis testing, followed by Dunn's pairwise comparisons were used to analyze differences in 30-day complication and readmission rates between cohorts. Statistical tests were two-sided with significance level set at α = 0.05. Thirty-day readmission was significantly higher in metropolitan teaching hospitals compared to metropolitan non-teaching and rural hospitals (p < 0.05). Metropolitan teaching hospitals had significantly higher rates of infection (p < 0.001), wound injury (p < 0.001), hematoma (p=0.018) and hardware failure (p < 0.002) compared to metropolitan nonteaching hospitals. Privately insured patients were significantly less likely to be readmitted at 30 days than Medicare or Medicaid beneficiaries (p < 0.01). Privately insured patients also experienced significantly lower rates of hematoma formation than Medicare patients and out-of-pocket payers (p < 0.01), wound injury compared to Medicaid patients and out-of-pocket payers (p < 0.005), and infection compared to all other groups (p < 0.001). Patients in Quartile 4 had significantly greater rates of hematoma formation than those in Quartiles 1 and 2 (p < 0.02) and were more likely to experience a thromboembolic event compared to all other groups (p < 0.002). Patients undergoing lumbar spine fusion at metropolitan nonteaching hospitals and paying with private insurance had significantly lower 30-day readmission rates than their counterparts. Complications within 30 days following lumbar spine fusion were significantly higher in patients treated at metropolitan teaching hospitals and in Medicare and Medicaid beneficiaries. Aside from a few exceptions, patient income was generally not associated with differential complication rates. Further understanding of how various hospital characteristics and sociodemographic factors may impact patient outcomes is essential in mitigating drivers of inequitable outcomes in patients undergoing lumbar spine fusion. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

In recent decades, overuse and misuse of opioids has led to a national epidemic of opioid-related harm in the United States, and chronic neck and back pain are a leading source of opioid prescriptions. Recent data suggest that chronic preoperative opioid use is a risk factor for complications following spine surgery as well as for postoperative opioid dependence, both of which increase health care expenditures. However, none of these studies focus on an older adult population. Older adults have shown increasing rates of opioid use disorders in recent decades and typically suffer more comorbidities and complications, and incur higher health care costs than the general population. This study investigated the degree to which chronic preoperative opioid use is a risk factor for postoperative complications, opioid dependence and insurance reimbursement in an older population undergoing anterior cervical discectomy and fusion (ACDF). Retrospective database study. Patients who underwent ACDF procedure. Postoperative complications, postoperative opioid dependence, and insurance reimbursement. Adults over 65 years-old who underwent ACDF between 2010 and 2020 were identified using a national insurance database. Patients with infection, spinal trauma or malignancy were excluded. Chronic preoperative opioid use was defined as active opioid prescription in three or more consecutive months before surgery. Postoperative opioid dependence was defined similarly for three months postoperatively. Insurance reimbursement was measured postoperatively at 3-month and 6-month intervals. Bivariate logistic regression was used to analyze the association between chronic preoperative opioid use and postoperative complications, chronic preoperative opioid use and postoperative opioid dependence, and chronic preoperative opioid use and insurance reimbursement. A total of 40,591 patients were included, of which 4,135 (10.2%) were prescribed chronic preoperative opioids and 25,300 (62.3%) were not prescribed any opioids preoperatively. Chronic preoperative opioid use was a risk factor for chronic opioid use postoperatively (OR=11.7, p<0.0001), readmission (OR=1.36, p<0.01), gastrointestinal complications (OR=1.36, p<0.001), and respiratory complications (OR=1.21, p<0.01). Mean reimbursements were higher for the chronic opioid group than the no opioids group at both the 3- and 6-month time points. This study demonstrates that chronic opioid use preceding ACDF is a risk factor for multiple postoperative medical complications as well as postoperative opioid dependence in elderly patients. The data suggest that patients with chronic opioid use preoperatively are unlikely to stop using opioids after surgery. Future studies should consider additional risk factors for postoperative opioid dependence, particularly those which are common in the older population, and alternatives to opioids for pain management prior to surgery. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Adjacent segment disease (ASD) is a possible complication following lumbar surgeries, particularly lumbar fusion. To investigate the clinical risk factors associated with developing radiological and/or clinical ASD following lumbar fusion. Systematic review and meta-analysis. Adult patients undergoing lumbar fusion. Clinical risk factors associated with the development of ASD. We performed a comprehensive literature search to find the relevant studies using PubMed, Embase, Medline, Scopus, and the Cochrane library databases from the beginning to December 2019. The titles and abstracts were used for initial screening, followed by a full-text review. The methodological index for non‐randomized studies (MINORS) criteria were used to evaluate the methodological quality of the included studies. A meta-analysis was conducted to calculate the odds ratio (OR) with the 95% confidence interval (CI) for dichotomous variables and mean difference (MD) with 95% CI for continuous variables. Both fixed and random-effects models were used to pool the data according to the observed heterogeneity. Thirty-five studies were included in the final qualitative analysis. Twenty-two of these studies were included in the risk factors meta-analyses. The mean quality score of the included studies was 12.4±1.9 (range, 8-16) points, based on the MINORS criteria. The level of evidence was low for many risk factors. Overall, 1,266 (17.2%) patients acquired ASD following lumbar fusion, and 6108 (82.8%) patients did not develop ASD, within a follow-up ranging between 20.5 - 165.6 months. Four clinical variables were found to have statistically significant risk factors for ASD, including higher preoperative body mass index (BMI) (mean difference [MD] = 1.97 kg/m2; 95% confidence interval [CI] = 1.49, 2.45; P < 0.001), floating fusion as compared to lumbosacral fusion (Odds ratio [OR] = 1.78; 95% CI = 1.32,2.41; P <0.001), superior facet joint violation (OR = 10.43; 95% CI = 6.4,17.01; P <0.001), and decompression outside fusion construct (OR = 1.72; 95% CI = 1.25, 2.37; P <0.001). Other factors that were analyzed and were not found to be risk factors for ASD included age (MD = 0.17 years; 95% CI = -0.60,0.94; P = 0.67), gender (OR = 0.91; 95% CI = 0.75,1.11; P = 0.36), smoking (OR = 1.26; 95% CI = 0.94,1.68; P = 0.12), diabetes (OR = 0.73; 95% CI = 0.51,1.05; P = 0.09), hypertension (OR = 1.33; 95% CI = 0.86 , 2.06; P = 0.20), osteoporosis (OR = 1.00; 95% CI = 0.64,1.57; P = 0.99), fusion approach (OR = 1.28; 95% CI = 0.65,2.51; P = 0.48), number of levels (OR = 0.87; 95% CI = 0.50,1.51; P = 0.62), intraoperative blood loss (MD = 12.39; 95% CI = -2.17,26.95; P = 0.10), and operative time (MD = 5.29; 95% CI = -0.15,10.74; P = 0.06). High preoperative BMI, floating fusion, superior facet joint violation, and decompression outside fusion construct are associated with a significant risk of developing ASD in patients undergoing lumbar fusion. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

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. 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). Retrospective database review. Patient cohort identified using MSpine national database that includes patients of all payer types who received fusion procedures. Complications examined included the following: neurologic, GI, respiratory, DVT and pulmonary embolism, pruritus, mental disorders, urinary incontinence and postoperative pain. 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. 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%). 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. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Malignant spinal tumors are common, continually increasing in incidence as a function of improved survival times for patients with cancer. Until recently, age has been popularly analyzed as an independent predictor of postoperative complications. However, frailty has been shown to be superior in predicting patient outcomes in spine surgery for several indications. Using predictive analytics and propensity score matching, we evaluated the influence of frailty on postoperative complications compared to age in patients with malignant neoplasms of the lumbar spine. Retrospective cohort study. A total of 533 frail patients and 538 nonfrail patients who underwent lumbar fusion with malignant spinal neoplasms within the Nationwide Readmissions Database (NRD). Mortality, infection, readmission, hardware failure, increased length of stay (LOS), nonroutine discharge, increased costs. Patient frailty was queried using the Johns Hopkins Adjusted Clinical Groups (JHACG) frailty-defining diagnosis indicator. Propensity score matching for age, sex, CCI, surgical approach, and number of levels fused was implemented between frail and nonfrail patients. Receiver operating characteristic (ROC) curves were created following creation of logistic regression models for relevant postoperative complications using both age and frailty status as predictor variables. The area under the curve (AUC) of each ROC served as a proxy for model performance. Despite matching, frail patients reported significantly higher inpatient lengths of stay (LOS), costs, infection, posthemorrhagic anemia, and urinary tract infections (p<0.05). In addition, frail patients were more often discharged to skilled nursing facilities and short-term hospitals compared to nonfrail patients (p<0.0001) when demographics and surgical variables were held constant. Regression models for mortality (AUC=0.644), nonroutine discharge (AUC=0.600), and acute infection (AUC=0.666) were all improved when using frailty as the primary predictor compared to models using age. 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, LOS, costs, and acute complications in patients receiving fusion following resection of a malignant neoplasm of the lumbar spine region. Frailty also demonstrated better predictive validity of outcomes compared to patient age. Further investigation is warranted to obtain higher AUCs and fully optimize the prediction of perioperative complications using frailty. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Neurologic complications of cervical spine surgery include C5 palsy, monoplegia, paraplegia and quadriplegia and can have significant impact on quality of life. C5 palsy has a reported incidence of 0-30% with few well-established risk factors. Postoperative cervical spine iatrogenic monoplegia, paraplegia and quadriplegia have little literature supporting their incidence. The Charlson Comorbidity Index is a measure of comorbidity in patients that is associated with surgical outcomes. The objective of this study was to identify the incidence and risk factors for severe neurological complications including C5 palsy after cervical spine surgery using a nationwide patient database. Retrospective database study. Patients from the Humana national database who underwent cervical spine surgery between 2007 and 2016. Neurological complications, CCI, patient demographics. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9), The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10), and Current Procedural Terminology (CPT) codes were used to identify and evaluate patients from the Humana national database for neurological complications following posterior fusion cervical spine surgery, anterior fusion cervical spine surgery, laminectomy/laminotomy of the cervical spine, and artificial disc replacement of the cervical spine. Neurological complications were evaluated over a 14-day postoperative period. Using Chi-squared testing, complication incidences and relative risk ratios were calculated with respect to type of cervical spine surgery, CCI, patient age, and patient sex. A total of 45,373 patients from the Humana database fit the inclusion criteria for cervical spine surgery. Of these, 732 (1.61%) patients experienced a neurological complication within 14 days after cervical spine surgery. C5 palsy had an incidence of 0.06% across all cervical spine surgeries (29 of 45,373 patients). A CCI >3 had a 5.44 times relative risk for any neurological complication (RR: 5.44; 95% CI: 4.70 - 6.30; p<<0.001) and a 2.85 times relative risk of C5 palsy complications (RR: 2.85; 95% CI: 1.37 - 5.92; p <0.05). The incidence of neurological complications varied by surgery: posterior fusion (4.56%), anterior fusion (1.10%), laminotomy (1.84%) and artificial disc replacement (1.08%). Compared to female patients, male patients had a 1.43x increased risk of neurological complications (RR: 1.43; 95% CI: 1.23-1.65; p<<0.001), but not C5 palsy (RR: 1.23, 95% CI: 0.59-2.56, p=0.57314). Patients 90 years of age and over had the highest incidence of neurological complications (10.26%). Incidence of neurological complications followed a linear increase as age increased. Patients who underwent cervical spine surgery and had a CCI > 3 were at a significantly increased relative risk for neurological complications including C5 palsy within 14 days after surgery. Compared to female patients, male patients had a statistically significant increased incidence in neurological complications, but no significant increase in incidence for C5 palsy. Posterior fusion cervical spine surgery had the highest incidence of neurological complications. Age was correlated with greater incidence of neurological complications. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT With the changing landscape of health care, outpatient spine surgery is more commonly performed to reduce cost and improve efficiency. Anterior cervical discectomy and fusion (ACDF) is one of the mo st common spine surgeries performed and demand is expected to increase with an aging population. PURPOSE The purpose of this study was to determine the nationwide trends and complication rates associated with outpatient ACDF as compared to inpatient ACDF. STUDY DESIGN/SETTING This study is a retrospective review utilizing the Humana subset of the PearlDiver insurance records database. PATIENT SAMPLE The patient sample consisted of patients undergoing single level ACDF (CPT-22551 AND ICD-9-816.2) as either outpatients or inpatients from 2011 to 2016. OUTCOME MEASURES Perioperative medical and surgical complications were identified by querying for relevant International Classification of Diseases and Current Procedural Terminology codes. METHODS The incidence of perioperative medical and surgical complications was determined after the database query was performed. Multivariate logistic regression adjusting for age, gender and Charlson Comorbidity Index was used to calculate odds ratios (OR) of complications among outpatients relative to inpatients undergoing ACDF. RESULTS Cohorts of 1,215 patients who underwent outpatient ACDF and 10,964 patients who underwent inpatient ACDF were identified. The median age was in the age 65-69 age group for both cohorts. The annual relative incidence of outpatient ACDF increased from 0.11 in 2011 to 0.22 in 2016 (R2=0.82, p=.04). Adjusting for age, gender and comorbidities, patients undergoing outpatient ACDF were more likely to undergo revision surgery for posterior fusion at both 6 months (OR 1.58, CI 1.27–1.96, p<.001) and one year postoperatively (OR 1.79, CI 1.51–2.13, p<.001). Outpatient ACDF patients were also more likely to undergo revision anterior fusion surgery with extension at one year postoperatively (OR 1.46, CI 1.26–1.70, p<.001). Rates of hardware removal, surgical wound exploration, dural tears, and neurological injury were statistically comparable. Among medical complications, postoperative acute renal failure was more frequently associated with outpatient ACDF than inpatient (OR 1.25, CI 1.06–1.49, p=.010), while the rates of major thromboembolic, respiratory, and cardiovascular events were statistically comparable. CONCLUSIONS Outpatient spine surgery is growing increasingly popular due to changes in health care delivery and greater attention to cost reduction and improved efficiency. Data collected from a national private insurance database demonstrates greater risk of perioperative surgical complications associated with outpatient ACDF, including revision anterior and posterior fusion, as well as higher risk for postoperative acute renal failure. Candidates for outpatient ACDF should be counseled and carefully selected to reduce these risks. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT 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. Considering the substantial similarity in neurologic outcomes following the two approaches, complication rates seem to be the key determinants in resolving the controversy over the optimal approach. PURPOSE To compare the complication rates between anterior and posterior decompression for degenerative thoracic spine disease. STUDY DESIGN/SETTING Retrospective database. PATIENT SAMPLE Patients with degenerative thoracic spine disease who had undergone anterior or posterior decompression between 2007 and 2015. OUTCOME MEASURES Charlson Comorbidity Index (CCI) as a broad measure of comorbidity; Intra-operative complications, including accidental organ puncture or laceration, hemorrhage and dural laceration; and major medical complications on the day of surgery, one month and three months after the surgery, including cardiovascular, central nervous system, infectious, respiratory and wound complications as well as organ failure and minor complications. METHODS A private insurance database (Humana) containing the medical records of over 68 million patients in United States was queried using the PearlDiver Patient Records Database (PearlDiver Technologies, Colorado Springs, CO, USA). Patients who had undergone anterior or posterior thoracic decompression were identified using the Current Procedural Terminology codes. Subsequently, records were screened for patients with degenerative diagnoses using the International Classification of Diseases 9th edition codes, and patients diagnosed with spinal neoplasm, trauma, fracture and infection were excluded. CCI was compared between groups using the Mann-Whitney U test. Incidence rates of complications were compared between the two approaches using the Chi-square statistics, and crude odds ratios (OR) with 95% confidence intervals (CI) were reported. RESULTS A total of 1,495 patients were included in this study, consisting of 1,030 patients in the posterior group and 465 patients in the anterior group. CCI was significantly higher in the posterior group (Md=2, IQR: 1-4) compared to the anterior group (Md=2, IQR: 2-2, p<.001). Two groups were comparable in terms of cardiovascular, central nervous system, infectious and wound complications, as well as major organ failure. However, patients in the anterior group were more likely to develop intra-operative complications (6.45% vs. 3.40%, OR=1.88, 95% CI: 1.14-3.10, p<.05) and respiratory complications on the day of surgery (13.98% vs. 9.51%, OR=1.55, 95% CI: 1.11-2.16, p<.05), during the first month (23.66% vs. 16.31%, OR=1.59, 95% CI: 1.21-2.08, p<.01) and within three months after surgery (24.95% vs. 18.45%, OR=1.47, 95% CI: 1.13-1.91, p<.01). Furthermore, patients in this group were more likely to develop minor complications on the day of surgery (5.81% vs. 2.62%, OR=2.29, 95% CI: 1.33-3.95, p<.01), within one month (9.89% vs. 6.21%, OR=1.66, 95% CI: 1.12-2.46, p<.05) and three months after surgery (10.97% vs. 7.48%, OR=1.52, 95% CI: 1.05-2.21, p<.05). CONCLUSIONS Despite having a lower overall comorbidity score, patients with degenerative thoracic spine diseases undergoing anterior decompression were more likely to develop intraoperative, respiratory and minor complications when compared to the posterior approach. High rates of respiratory complications following the anterior approach underline the importance of special respiratory care for these patients. Future studies may focus on predictive factors of respiratory compromise following thoracic decompression, aiming to identify the patients at risk who may benefit from posterior decompression. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]