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Background context There are often multiple surgical treatment options for a spinal pathology. In addition, there is a lack of data that define differences in surgical treatment among surgeons in the United States. Purpose To assess the surgical treatment patterns among neurologic and orthopedic spine surgeons in the United States for the treatment of one- and two-time recurrent lumbar disc herniation. Study design Electronic survey. Patient sample An electronic survey was delivered to 2,560 orthopedic and neurologic surgeons in the United States. Outcome measures The response data were analyzed to assess the differences among respondents over various demographic variables. The probability of disagreement is reported for various surgeon subgroups. Methods A survey of clinical and radiographic case scenarios that included a one- and two-time lumbar disc herniation was electronically delivered to 2,560 orthopedic and neurologic surgeons in the United States. The surgical treatment options were revision microdiscectomy, revision microdiscectomy with in situ fusion, revision microdiscectomy with posterolateral fusion using pedicle screws, revision microdiscectomy with posterior lumbar interbody fusion/transforaminal lumbar interbody fusion (PLIF/TLIF), anterior lumbar interbody fusion (ALIF) with percutaneous screws, ALIF with open posterior instrumentation, or none of these. Significance of p=.01 was used to account for multiple comparisons. Results Four hundred forty-five surgeons (18%) completed the survey. Surgeons in practice for 15+ years were more likely to select revision microdiscectomy compared with surgeons with fewer years in practice who were more likely to select revision microdiscectomy with PLIF/TLIF (p<.001). Similarly, those surgeons performing 200+ surgeries per year were more likely to select revision microdiscectomy with PLIF/TLIF than those performing fewer surgeries (p=.003). No significant differences were identified for region, specialty, fellowship training, or practice type. Overall, there was a 69% and 22% probability that two randomly selected spine surgeons would disagree on the surgical treatment of two- and one-time recurrent disc herniations, respectively. This probability of disagreement was consistent over multiple variables including geographic, practice type, fellowship training, and annual case volume. Conclusions Significant differences exist among US spine surgeons in the surgical treatment of recurrent lumbar disc herniations. It will become increasingly important to understand the underlying reasons for these differences and to define the most cost-effective surgical strategies for these common lumbar pathologies as the United States moves closer to a value-based health-care system. [ABSTRACT FROM AUTHOR]

Abstract: Background context: Allograft bone is commonly used in various spinal surgeries. The large amount of recalled allograft tissue, particularly in recent years, has increased concerns regarding the safety of allograft bone for spinal surgery. An analysis of allograft recall and its safety in spinal surgery has not been reported previously. Purpose: To determine 1) the number and types of allograft recall and the reasons for recall, 2) the types of disease transmission to spine patients, and 3) assess the safety of allograft bone in spinal surgery. Study design/setting: Retrospective review. Methods: A retrospective review of all Food and Drug Administration (FDA) data from 1994 to June 2007 was reviewed to determine the amount and types of recalled allograft tissue. The literature and data from the Center for Disease Control were reviewed to determine the number and types of disease transmissions from allograft bone that have occurred to spine surgery patients during the study period. Results: There were 59,476 musculoskeletal allograft tissue specimens recalled by FDA during the study period, which accounts for 96.5% of all allograft tissue recalled in the United States. Improper donor evaluation, contamination, and recipient infections are the main reasons for allograft recall. There has been one case of human immunodeficiency virus infection transmission to a spine surgery patient in 1988. This is the only reported case of viral transmission. There are no reports of bacterial disease transmission from the use of allograft bone to spine surgery patients. Conclusions: The precise number of allografts used in spine surgery annually and the precise incidence of disease transmission to spine surgery patients linked to the use of allograft tissue is unknown. Musculoskeletal allograft tissue accounts for the majority of recalled tissue by FDA. Despite the large number of allograft recalls in this country, there is only one documented case in the literature of disease transmission to a spine surgery patient. There appears to be no overt risk associated with the use of allograft bone in spine surgery. However, as discussed in this article, there are certain aspects regarding the use of allograft bone that should be considered. [Copyright &y& Elsevier]

COMMENTARY ON: Comer GC, Smith MW, Hurwitz EL, et al. Retrograde ejaculation after anterior lumbar interbody fusion with and without bone morphogenetic protein-2 augmentation: a 10-year cohort controlled study. Spine J 2012;12:881–90 (in this issue). [Copyright &y& Elsevier]

Background Context: Preoperative TNF-AI use has been associated with increased rate of postoperative infections and complications in a variety of orthopedic procedures. However, the association between TNF-AI use and complications following spine surgery has not yet been studied.Purpose: The purpose of the present study was to assess the risk of reoperation in patients prescribed TNF-AI undergoing spinal fusion surgery.Study Design: This is a retrospective review.Patient Sample: A total of 427 patients who underwent spinal fusion surgery at a large healthcare system from 1/1/2009 to 12/31/2018.Outcome Measure: Reoperation within 1 year.Methods: We retrospectively reviewed the records of patients who underwent spinal fusion surgery at a large healthcare system from 1/1/2009 to 12/31/2018. There were three distinct cohorts of spine surgery patients under study: patients with TNF-AI use in 90 days before surgery, patients with non-TNF-AI DMARD medications use in the 90 days before surgery, and patients taking neither TNF-AI nor other DMARD medications in 90 days before surgery. The primary outcome of interest was reoperation for any reason within 1 year following surgery.Results: Our study included 90 TNF-AI, 90 DMARD, and 123 control patients. Reoperation up to 1-year postsurgery occurred in 19% (n=17) of the TNF-AI group, 11% (n=10) of the DMARD group, and 6% (n=7) of the control group. The reasons for reoperation for TNF-AI group were 47% (n=8) infection and 53% (n=9) other causes which included failure to fuse and adjacent segment disease. Reasons for reoperation at 1 year were 40% (n=4) infection and 60% (n=6) other causes for DMARD patients and 14% (n=1) infection with 86% (n=6) other causes for control patients. The cox-proportional hazard model of reoperation within 1 year indicated that the odds of reoperation were 3.1 (95% CI:1.4-7.0) and 2.2 (95% CI 0.96-5.3) times higher in the TNF-AI and DMARD groups, respectively, compared to the control group.Conclusions: Patients taking TNF-AIs before surgery were found to have a significantly higher rate of reoperation in the 1 year following surgery compared to controls. The higher rate of reoperation associated with TNF-AI use before spinal fusion surgery represents the potential for higher morbidity and costs for patient which is important to consider for both surgeon and patient in preoperative decision making. [ABSTRACT FROM AUTHOR]

Approximately 250,000 patients per year who are on anticoagulants must interrupt their regimen to undergo surgery or an invasive procedure that poses a high risk for blood loss. These patients must be properly managed in order to balance the prevention of thromboembolic events with excessive bleeding risk during surgery. Current guidelines for the timing of preoperative interruption and postoperative resumption of long-term anticoagulant therapy have been outlined but are based on methodologically weak observational studies and low quality data.The ambiguity of the existing data is reflected in the postoperative anticoagulant management of many spine surgeons. While some surgeons are willing to restart postoperative anticoagulants soon after surgery, others choose to wait for fear of bleeding complications. While spine surgery patients represent a unique cohort at high risk for bleeding complications, data exploring perioperative anticoagulation management for this population is lacking. To determine the postoperative day of anticoagulant resumption in spine surgery patients that minimizes thromboembolic complications. This was a retrospective cohort study of spine surgery patients within one hospital system. The study included 1,441 patients who stopped medical anticoagulation for a spine surgery between the years 2008 and 2018 and who resumed anticoagulation while inpatients postoperatively. The primary outcome measure was incidence of thromboembolic complication, defined as cerebrovascular accident (CVA), myocardial infarction (MI), pulmonary embolism (PE), or deep vein thrombosis (DVT). All patients undergoing fusion or decompression spinal surgery between the years 2008-2018 who were medically anticoagulated within 14 days prior to surgery and who resumed anticoagulation while inpatient were studied. Ten independent predictors of thromboembolic events were examined: postoperative day of anticoagulant resumption, age, sex, race, aspirin use, Charlson Comorbidity Index (CCI), fusion as a component of surgery, multilevel surgery, and length of stay. Multivariate logistic regression analysis was used to identify which predictors increased the odds of a thromboembolic event. Of the 1,441 patients studied, 418 (29%) were restarted on anticoagulation on postoperative day (POD) #1, another 603 (41%) were restarted on POD#2, and 420 (29%) were restarted on POD#3 or later. Patients restarted on POD#3 or greater had an increased risk of thromboembolic events (OR 1.63, p = 0.038, 95% CI = 1.02 - 2.6). Other risk factors for clotting events included black race (OR 1.96, p = 0.007, 95% CI = 1.19 - 3.2), CCI greater than 3 (CCI 3-4: OR 2.67, p =.006; CCI 5-6: OR 3.04, p =.003; CCI 7+: OR 3.53, p <.001), and length of stay (OR 1.06 for each additional day, p <.001). In our study of medically anticoagulated patients undergoing spine surgery, resumption of anticoagulants on POD#3 or greater increased the risk of thromboembolic complications. This finding further reinforces recent literature suggesting that a conservative approach when resuming anticoagulants after surgery can lead to serious complications. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective cohort study using prospectively collected data OBJECTIVE.: Determine the association between satisfaction with physician communication and patient reported outcomes in the inpatient spine surgery setting.Summary Of Background Data: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys measure the patient experience of care and influence reimbursement for hospital systems and providers in the United States. It is not known whether patient satisfaction with physician communication is associated with better outcomes following spine surgery. Therefore, we evaluated the association between patient satisfaction with physician communication on the HCAHPS survey and improvements in validated patient-reported outcomes measures in a spine surgery population.Methods: HCAHPS responses were obtained for patients undergoing elective cervical or lumbar spine surgery from 2013 to 2015. Patient reported health status measures were the primary outcomes, including EuroQol Five Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and Visual Analog Scores for Back and Neck Pain (VAS-BP/NP). The association between satisfaction with communication and pre- to one-year postoperative changes in each health status measure were evaluated utilizing multivariable linear regression models.Results: Our study included 648 patients, of which, 479 (74.4%) created our satisfied cohort. Demographically, our two cohorts were similar with regards to pre-operative clinical measures, however the satisfied cohort had a higher self-rating of their mental health (p < 0.01), and overall health (p < 0.01). After adjusting for clinically relevant confounders, our results demonstrated no significant association between satisfaction with physician communication and improvement in EQ-5D (p = 0.312), PDQ (p = 0.498), or VAS pain scores (p = 0.592).Conclusion: Patient satisfaction with physician communication was not associated with one-year postoperative improvement in EQ-5D, PDQ, and VAS-Pain following spine surgery. These findings do not diminish the importance of effective communication between doctor and patient, but instead suggest that within the spine surgery setting, using only patient experience data may not accurately reflect the true quality of care received during their inpatient stay.Level Of Evidence: 4. [ABSTRACT FROM AUTHOR]

Background Context: Prior studies have shown that patient-reported allergies can be prognostic of poorer postoperative outcomes.Purpose: The objective of this study was to investigate the correlation between self-reported allergies and outcomes after cervical or lumbar spine surgery.Study Design/setting: This is a retrospective cohort study at a single tertiary care institution.Patient Sample: The patient sample included all patients undergoing cervical or lumbar spine surgery from 2009 to 2014.Outcome Measures: The primary outcome measure was change in the EuroQol-5 Dimensions (EQ-5D) after surgery. Secondary outcomes included changes in the Pain Disability Questionnaire (PDQ) and in the Patient Health Questionnaire-9 (PHQ-9), achievement of the minimal clinically important difference (MCID) in these measures, and cost of admission.Methods: Before and after surgery, EQ-5D, PDQ, and PHQ-9 were recorded for patients with available data. Paired Student t tests were used to compare changes in these measures after surgery. Multivariable linear and logistic regressions were used to assess the relationship between the log transformation of the total number of allergies and outcomes.Results: A total of 592 cervical patients and 4,465 lumbar patients were included. The median number of reported allergies was two. The EQ-5D index increased from 0.539 to 0.703 for cervical patients and from 0.530 to 0.676 for lumbar patients (p<.01 for both). Patients experienced significant pain improvement by the PDQ (80.1-58.2 for cervical patients and 79.4-58.1 for lumbar patients, p<.01). Using multivariable logistic regression, the log transformation of the number of allergies predicted significantly higher odds of achieving the PDQ MCID (odds ratio [OR]=2.09, 95% confidence interval [CI] 1.05-4.15, p=.02, for cervical patients; OR=1.30, 95% CI 1.03-1.68, p=.03, for lumbar patients). However, this relationship was not durable for patients with follow-up exceeding 1 year. The log transformation of the number of allergies for lumbar patients predicted a significantly increased cost of admission (β=$3,597, p<.01) and trended toward significance among cervical patients (β=$1,842, p=.10).Conclusions: Patient-reported allergies correlate with subjective improvement in pain and disability after spine surgery and may serve as a marker of postoperative outcomes. The relationship between allergies and PDQ improvement may be secondary to the short-term expectation-actuality discrepancy, as this relationship was not durable beyond 1 year. [ABSTRACT FROM AUTHOR]

Background Context: Relative value units (RVUs) are a compensation model based on the effort required to provide a procedure or service to a patient. Thus, procedures that are more complex and require greater technical skill and aftercare, such as multilevel spine surgery, should provide greater physician compensation. However, there are limited data comparing RVUs with operative time. Therefore, this study aims to compare mean (1) operative times; (2) RVUs; and (3) RVU/min between posterior segmental instrumentation of 3-6, 7-12, and ≥13 vertebral segments, and to perform annual cost difference analysis.Methods: A total of 437 patients who underwent instrumentation of 3-6 segments (Cohort 1, current procedural terminology [CPT] code: 22842), 67 patients who had instrumentation of 7-12 segments (Cohort 2, CPT code: 22843), and 16 patients who had instrumentation of ≥13 segments (Cohort 3, CPT code: 22844) were identified from the National Surgical Quality Improvement Program (NSQIP) database. Mean operative times, RVUs, and RVU/min, as well as an annualized cost difference analysis, were calculated and compared using Student t test. This study received no funding from any party or entity.Results: Cohort 1 had shorter mean operative times than Cohorts 2 and 3 (217 minutes vs. 325 minutes vs. 426 minutes, p<.05). Cohort 1 had a lower mean RVU than Cohorts 2 and 3 (12.6 vs. 13.4 vs. 16.4). Cohort 1 had a greater RVU/min than Cohorts 2 and 3 (0.08 vs. 0.05, p<.05; vs. 0.08 vs. 0.05, p>.05). A $112,432.12 annualized cost difference between Cohorts 1 and 2, a $176,744.76 difference between Cohorts 1 and 3, and a $64,312.55 difference between Cohorts 2 and 3 were calculated.Conclusion: The RVU/min takes into account not just the value provided but also the operative times required for highly complex cases. The RVU/min for fewer vertebral level instrumentation being greater (0.08 vs. 0.05), as well as the $177,000 annualized cost difference, indicates that compensation is not proportional to the added time, effort, and skill for more complex cases. [ABSTRACT FROM AUTHOR]

Background Context: The patient experience of care as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is currently used to determine hospital reimbursement. The current literature inconsistently demonstrates an association between patient satisfaction and surgical outcomes.Purpose: To determine whether patient satisfaction with hospital experience is associated with better clinical outcomes in lumbar spine surgery.Study Design: A retrospective cohort study conducted at a single institution.Patient Sample: A total of 249 patients who underwent lumbar spine surgery between 2013 and 2015 and completed the HCAHPS survey.Outcome Measures: Self-reported health status measures, including the EuroQol 5 Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and visual analog score for back pain (VAS-BP).Methods: All patients undergoing lumbar spine surgery between 2013 and 2015 who completed an HCAHPS survey were studied. Patients were excluded from the study if they had been diagnosed with spinal malignancy, scoliosis, or had less than 1 year of follow-up. Patients who selected a 9 or 10 overall hospital rating (OHR) on HCAHPS were placed in the satisfied group, and the remaining patients comprised the unsatisfied group. The primary outcomes of this study include patient-reported health status measures such as EQ-5D, PDQ, and VAS-BP. No funds were received in support of this study, and the authors report no conflict of interest-associated biases.Results: Our study population consisted of 249 patients undergoing lumbar spine surgery. Of these, 197 (79%) patients selected an OHR of 9 or 10 on the HCAHPS survey and were included in the satisfied group. The only preoperative characteristics that differed significantly between the twogroups were gender, a diagnosis of degenerative disc disease (DDD), heavy preoperative narcotic use, and a diagnosis of chronic renal failure. At 1 year follow-up, no statistically significant differences in EQ-5D, PDQ, or VAS-BP were observed. After using multivariable linear regression models to assess the association between patient satisfaction and pre- to 1-year postoperative changes in health status measures, selecting a top-box OHR was not found to be significantly associated with change in either EQ-5D (beta=0.055 [95% confidence interval {CI}: -0.035 to 0.145]), PDQ (beta=-9.013 [95% CI: -23.782 to 5.755]), or VAS-BP (beta=-0.849 [95% CI: -2.125 to 0.426]). These results suggest high satisfaction with the hospital experience may not necessarily correlate with favorable clinical outcomes.Conclusions: Top-box OHR was not associated with pre- to 1-year postoperative improvement in EQ-5D, PDQ, and VAS-BP. Although the associations between high satisfaction and improvement in health status did not reach statistical significance, the best estimates from our multivariable models reflect greater clinical improvement with top-box satisfaction. Future studies should seek to investigate whether HCAHPS are a reliable indicator of quality care in lumbar spine surgery. [ABSTRACT FROM AUTHOR]

Study Design: A retrospective cohort study at a single institution.Objective: To determine the effect of preoperative depression on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores in a lumbar fusion population.Summary Of Background Data: HCAHPS surveys are used to assess the quality of the patient experience, and directly influences reimbursement for hospital systems and spine surgeons nationwide. Untreated depression has been linked to worse functional outcomes in spine surgery. We, however, aimed to elucidate whether HCAHPS survey responses were different in depressed patients.Methods: Prospectively collected functional outcome data including Patient Health Questionnaire 9, EuroQol five dimensions, and Pain Disability Questionnaire were analyzed preoperatively. Preoperative Patient Health Questionnaire 9 scores of greater than or equal to 10 (moderate to severe depression) defined our depressed cohort of patients. HCAHPS responses were obtained for each individual, allowing for real-world analysis of outcomes in this population.Results: In our 237 patient cohort, depressed patients were younger, female; were on full disability; and had lower scores on EuroQol five dimensions and Pain Disability Questionnaire preoperatively. Approximately 73.2% of depressed patients felt doctors treated them with respect, compared to 88.8% of patients without depression (P = 0.005). Also, depressed patients felt nurses treated them with less respect (P = 0.014) and that physicians did not listen to them as carefully (P = 0.029). Multivariate regression analysis revealed that patients with preoperative depression had higher odds of patients feeling less respected by both physicians and nurses. Multivariate analysis also revealed that depression was an independent predictor of lower patient satisfaction with nursing response to their needs.Conclusion: In patients undergoing lumbar fusion, preoperative depression was shown to have negative effect on patient experience measured by the HCAHPS survey. These results suggest that depression may be a modifiable risk factor for poor hospital experience.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

Background Context: Coexisting Parkinson's disease (PD) and cervical spondylotic myelopathy (CSM) presents a diagnostic and therapeutic challenge due to symptomatic similarities between the diseases. Whereas CSM patients are routinely treated with surgery, PD patients face poorer outcomes following spine surgery. No studies have investigated the quality of life (QOL) outcomes following decompression in coexisting PD and CSM.Purpose: The purpose of the present study was to characterize QOL outcomes for patients with coexisting PD and CSM following cervical decompression.Study Design/setting: This is a matched cohort study at a single tertiary-care center.Patient Sample: Patients with coexisting PD and CSM undergoing cervical decompression between June 2009 and December 2014 were included. These patients were matched to controls with CSM alone by age, gender, American Society of Anesthesiologists classification, Modified Japanese Orthopaedic Association scores, and operative parameters.Outcome Measures: The primary outcome measure was QOL outcomes assessed by change in the EuroQol 5-Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and Patient Health Questionnaire-9 (PHQ-9) at last follow-up (LFU). Change in QOL exceeding the minimal clinically important difference (MCID) was secondary.Methods: QOL data were collected using the institutional prospectively collected database of patient-reported health status measures. Simple and multivariable regressions were used to assess the impact of PD upon change in QOL.Results: Eleven PD patients were matched to 44 controls. Control patients experienced QOL improvement across all three measures, whereas PD patients only improved with respect to PDQ(89.9-80.7, p=.03). Despite no significant differences in preoperative QOL, PD patients experienced poorer QOL at LFU in EQ-5D (0.526 vs. 0.707, p=.01) and PDQ (80.7 vs. 51.4, p=.03), and less frequently achieved an EQ-5D MCID (18% vs. 57%, p=.04). However, no differences in the achievement of an MCID in PDQ or PHQ-9 were observed between cohorts. Multivariable regression identified PD as a significant independent predictor of poorer improvement in EQ-5D (β=-0.09, p<.01) and failure to achieve an EQ-5D MCID (odds ratio: 0.08, p<.01).Conclusions: This is the first study to characterize QOL outcomes following cervical decompression for patients with coexisting PD and CSM. Although myelopathy may have been less severe among PD patients, a significant reduction in pain-related disability was observed following decompression. However, PD predicted diminished improvement in overall QOL measured by the EQ-5D. [ABSTRACT FROM AUTHOR]

Study Design: Electronic survey.Objective: To identify the surgical treatment patterns for low back pain (LBP), among U.S. spine surgeons. Specifically determine (1) differences in surgical treatment responses based on various demographic variables; (2) probability of disagreement based on surgeon subgroups.Summary Of Background Data: Multiple surgical and nonsurgical treatments exist for LBP. Without strong evidence or clear guidelines for the indications and optimal treatments, there is substantial variability in surgical treatments used.Methods: A total of 445 U.S. spine surgeons completed a survey of clinical and radiographic case scenarios on patients with mechanical LBP, no leg pain, and concordant discograms. Surgical treatment options included no surgery, anterior lumbar interbody fusion (ALIF), posterolateral fusion with pedicle screws, transforaminal/posterior lumbar interbody fusion (TLIF/PLIF), etc. Statistical significance was set at 0.01 to account for multiple comparisons.Results: There was substantial clinical equipoise (∼75% disagreement) among surgeons on the approach to treat patients with LBP. Disagreement was highest in the southwest and lowest in the Midwest (82% vs. 69%, respectively); there was significantly lower disagreement among those in academic practices versus those in private/hybrid practices (56% vs.79%, respectively). Those in academic practices had approximately four times greater odds of choosing no surgery as compared to those in hybrid and private practices, who were more likely to choose ALIF or PLIF/TLIF. Those with fellowship training had approximately two times greater odds of selecting no surgery and four times greater odds of selecting ALIF as compared to those without fellowship training who were more likely to select TLIF/PLIF.Conclusion: Significant differences exist among U.S. spine surgeons in the treatment of LBP. These differences stem from geographical location of the practice, specialty, practice type, and fellowship training. Recognizing the substantial variability underlies the importance of additional studies aimed at identifying the proper indications and most cost-effective treatments for LBP.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

Background Context: Patients with comorbid disease may experience suboptimal quality of life (QOL) improvement following decompression spinal surgery. Prior studies have suggested the deleterious effect of diabetes upon postoperative QOL; however, these studies have not used minimal clinically important differences (MCIDs) or multivariable statistical techniques.Purpose: The purpose of this study was to assess the effect of preoperative diabetes upon postoperative change in QOL.Study Design/setting: A retrospective cohort study at a single tertiary-care center was carried out.Patient Sample: Patients who underwent lumbar decompression between 2008 and 2014 were included in the study. Inclusion necessitated a minimum follow-up of 6 months.Outcomes Measures: Postoperative changes in the EuroQol 5-Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and Patient Health Questionnaire 9 (PHQ-9) at last follow-up were the primary outcome measures. The secondary outcome variable was postoperative change in QOL measures exceeding the MCID.Methods: Quality of life data were collected using the institutional prospectively collected database of patient-reported health status measures. Simple and multivariable logistic regressions were used to assess the impact of diabetes upon normalized change in QOL and improvement exceeding the MCID.Results: There were 212 patients who met inclusion criteria. Whereas non-diabetics experienced significant improvements in EQ-5D, PDQ, and PHQ-9 (p<.01), diabetics experienced no significant changes in any measures. More non-diabetics achieved the EQ-5D MCID compared with diabetics (55% vs. 23%, p<.01). Following multivariable regression, chronic kidney disease (CKD, β=-0.15, p=.04) and diabetes (β=-0.05, p=.04) were identified as significant independent predictors of diminished improvement in EQ-5D postoperatively. Furthermore, diabetes was also identified as a significant independent predictor of failure to achieve an EQ-5D MCID (OR 0.20, p<.01), whereas CKD trended toward predicting diminished improvement (OR<0.01, p=.09).Conclusion: The burden of comorbidities may impact the QOL benefit of decompression spine surgery. In the present study, diabetes was found to independently predict diminished improvement in QOL after lumbar decompression. [ABSTRACT FROM AUTHOR]

Study Design: A critical review of the current literature. Objective: The purpose of this study was to determine frequency, trends, and methods of utilization of spine-related PROIs over the last 10 years. Summary Of Background Data: Patient-reported outcome instruments (PROIs) have become the gold standard to assess the efficacy of various medical and surgical treatments. Currently, however, there is an expansive range of PROIs without a clear consensus or guideline addressing which PROIs should be used for a particular diagnosis or surgical intervention. Methods: A PubMed search was conducted from 2004 to 2013 of 5 orthopedic journals (The Journal of Bone and Joint Surgery, The Bone and Joint Journal, The Spine Journal, The European Spine Journal, and Spine) that publish spine articles, chosen on the basis of readership and impact factor. Journal abstracts were inspected for spine surgery and inclusion of at least 1 PROI. All articles containing PROIs and investigating a surgical intervention with a level of evidence (LOE) 1 to 4 were included for analysis. Article title, LOE, journal, and chosen PROI were recorded for selected articles. Results: Out of 19,736 articles published in our selected time frame, 1,079 utilized PROIs. Most studies were LOE 4 (32.7%). Nearly half (48.9%) of all articles addressed degenerative thoracolumbar conditions. In total, there were 206 unique PROIs in the studies chosen for inclusion. The top 6 instruments utilized were the (1) visual analog scale, (2) Oswestry disability index, (3) Short Form-36, (4) Japanese Orthopaedic Association Outcome Questionnaire, (5) Neck Disability Index, and (6) Scoliosis Research Society-22. Conclusion: The breadth of PROIs in spine surgery is extensive. Although there are preferred patient-reported outcome measures, a consensus or guideline addressing which instruments should be used for a particular diagnosis or procedure may be warranted. Level Of Evidence: 4. [ABSTRACT FROM AUTHOR]

Background context Lumbar degenerative spondylolisthesis (LDS) is often diagnosed by conventional supine magnetic resonance imaging (MRI). Numerous studies have shown, however, that the degree of spondylolisthesis can be reduced or disappears when the patient is supine as compared with standing lateral and flexion-extension (SLFE) radiographs. Purpose To compare the sensitivity of supine MRI with SLFE radiographs in patients with L4–L5 LDS. Study design A retrospective imaging study. Patient sample Included patients diagnosed with L4–L5 LDS with both SLFE films and supine MRI. Methods Lumbar degenerative spondylolisthesis was defined radiographically as a slip greater than 4.5 mm. Mobile LDS was defined as a difference of greater than 3% in slip percentage between lateral radiographs and sagittal MRIs. Additional measurements included L4–L5 facet effusion diameter on axial MRIs. Measurements were performed by two independent examiners. The kappa coefficient was used to assess the interobserver agreement. Results Of 103 patients assessed, 68% were women and the average age was 66 years. Lumbar degenerative spondylolisthesis was seen on 101 (98%) lateral films and 80 (78%) MRIs. Average slip was 10.0 mm for lateral standing radiographs and 6.6 mm on MRI (p<.0001). Fifty (48%) patients were identified with mobile LDS. The positive predictive value of facet joint effusion for mobile LDS increased from 52% for effusions greater than 1 mm to 100% for effusions greater than 3.5 mm. Conclusions This study found that MRI had a sensitivity of 78% for detecting L4–L5 LDS compared with 98% for lateral standing films. We also identified facet effusion size as a marker to predict mobile LDS. These findings suggest that, particularly in the setting of facet effusions, the complete workup of patients in whom LDS is possible should include standing radiographs. [ABSTRACT FROM AUTHOR]

Study Design. Systematic review. Objective. To evaluate literature comparing fusion rates in anterior lumbar interbody fusion (ALIF), posterior lumbar interbody/transforaminal lumbar interbody fusion (PLIF/TLIF), and posterolateral lumbar fusion (PLF) with and without recombinant human bone morphogenetic protein-2 (rhBMP-2). Summary of Background Data. rhBMP-2 is used for the FDA-approved indication of single-level ALIF with LT-Cage and off-label for PLIF/TLIF, and PLF. Due to recent controversies, it is essential to evaluate the literature for its effects on fusion rates to evaluate whether benefits outweigh potential complications. Methods. A Medline search was performed of clinical studies published between May 2000 and May 2012 comparing fusion rates after ALIF, PLIF/TLIF, and PLF surgery with versus without rhBMP-2. Only studies with a control arm were reviewed. Results. 16 studies were reviewed (1794 patients, 995 treated with rhBMP-2 and 799 without). 5 of 5 studies for PLIF/TLIF (including 301 of 301 patients), 1 of 4 for ALIF (including 279 of 589 patients), and 3 of 7 for PLF (including 272 of 904 patients) reported no significant improvement in fusion rates with rhBMP-2 compared with those without rhBMP-2 at longest follow-up investigated. Average fusion rate 24 months after surgery was 97.8% for ALIF (n = 316), 95.7% for PLIF/TLIF (n = 141), and 93.6% for PLF (n = 422) with rhBMP-2 and 88.2% (n =228), 89.5% (n =86), and 83.1% (n =372) without rhBMP-2, for ALIF, PLIF/TLIF, and PLF, respectively. Odds ratio of fusion were calculated as 7.08 (95% CI: 1.54-32.7) in ALIF, 1.98 (95% CI: 0.39-10.1) in PLIF/TLIF, and 3.06 (95% CI: 1.61-5.80) in PLF with rhBMP-2 as compared with without rhBMP-2. Conclusion. Although numerous studies did not show statistically significant improvement in fusion rates with rhBMP-2 use, analysis of combined studies revealed significant improvement in fusion rate with rhBMP-2 in ALIF and PLF patients. Notably, even when pooling data from several studies, rhBMP-2 did not result in statistically significantly improved fusion rates in PLIF/TLIF. However, heterogeneity of rhBMP-2 dosing, surgical techniques, and quality of papers reviewed may limit the validity of conclusions drawn. [ABSTRACT FROM AUTHOR]

Abstract: Background context: Decompressive procedures such as laminectomy, facetectomy, and costotransversectomy are routinely performed for various pathologies in the thoracic spine. The thoracic spine is unique, in part, because of the sternocostovertebral articulations that provide additional strength to the region relative to the cervical and lumbar spines. During decompressive surgeries, stability is compromised at a presently unknown point. Purpose: To evaluate thoracic spinal stability after common surgical decompressive procedures in thoracic spines with intact sternocostovertebral articulations. Study design: Biomechanical cadaveric study. Methods: Fresh-frozen human cadaveric spine specimens with intact rib cages, C7–L1 (n=9), were used. An industrial robot tested all spines in axial rotation (AR), lateral bending (LB), and flexion-extension (FE) by applying pure moments (±5 Nm). The specimens were first tested in their intact state and then tested after each of the following sequential surgical decompressive procedures at T4–T5 consisting of laminectomy; unilateral facetectomy; unilateral costotransversectomy, and subsequently instrumented fusion from T3–T7. Results: We found that in all three planes of motion, the sequential decompressive procedures caused no statistically significant change in motion between T3–T7 or T1–T12 when compared with intact. In comparing between intact and instrumented specimens, our study found that instrumentation reduced global range of motion (ROM) between T1–T12 by 16.3% (p=.001), 12% (p=.002), and 18.4% (p=.0004) for AR, FE, and LB, respectively. Age showed a negative correlation with motion in FE (r=−0.78, p=.01) and AR (r=−0.7, p=.04). Conclusions: Thoracic spine stability was not significantly affected by sequential decompressive procedures in thoracic segments at the level of the true ribs in all three planes of motion in intact thoracic specimens. Age appeared to negatively correlate with ROM of the specimen. Our study suggests that thoracic spinal stability is maintained immediately after unilateral decompression at the level of the true ribs. These preliminary observations, however, do not depict the long-term sequelae of such procedures and warrant further investigation. [Copyright &y& Elsevier]

The article presents a study which measured radiation exposure to the eye, chest and hand of the operating surgeon during minimally invasive surgery (MIS) and open lumbar microdiscectomy to calculate the allowable number of cases per year from the mean values at each of the three sites using the Occupational Exposure Guidelines. It was found that surgeons are more significantly exposed to radiation during MIS lumbar microdiscectomy than open microdiscectomy. Protection in a substerile room during x-ray localization is said to be not guaranteed.

Several studies address the question of whether to extend a long-segment, posterior cervical fusions into the upper thoracic spine. Recommendations for appropriate caudal "end level" continue to vary. This systematic review seeks to compare fusion, reoperation and complication rates, estimated blood loss (EBL) and surgical time between multilevel instrumented fusions ending in the cervical spine and those that extend into the thoracic spine. Systematic review and Meta-analysis. Fusion, reoperation and complication rates, EBL and surgical time. A comprehensive computerized literature search through multiple electronic databases without date limits up until April Week 3 2020 using combinations of key search terms and inclusion/exclusion criteria was performed. Our comprehensive literature search yielded 3,852 studies. Of these, 8 articles consisting of 1,162 patients were included in the meta-analysis. In 61.2% of the patients the fusion did not cross the CTJ (the cervical end level CEL). In the remaining 38.8%, fusion extended into the upper thoracic spine (thoracic end level, TEL). Mean age of CEL group ranged from 57 to 67.8 years, and for TEL group, it was 55 to 65.3 years. Our direct analysis showed that odds of fusion were not statistically different between CEL and TEL groups (OR: 0.648, 95% CI: 0.336-1.252, p=0.197). Similarly, odds of reoperation (OR:0.726, 95% CI:0.493-1.068, p=0.104) and complication rates were similar between the two groups (OR:1.299, 95% CI:0.536-3.149, p=0.563). Standardized mean difference (SMD) for the blood loss (SMD: 0.728, 95% CI:0.554-0.901, p=0.000) and operative (SMD:0.653, 95% CI: 0.479-0.826, p=0.000) differed significantly between the two groups. The indirect analysis showed similar fusion (Effect Size (ES)crossing: 0.892, 95% CI: 0.840-0.928 vs ES not crossing:0.894, 95% CI:0.849-0.926); reoperation rate (EScrossing:0.112, 95% CI:0.075-0.164 vs ES not crossing: 0.125, 95% CI: 0.071-0.211) and complication rates (EScrossing: 0.108, 95% CI: 0.074-0.154 vs ES not crossing:0.081, 95% CI: 0.040-0.156). Our meta-analysis showed that fusion, complication and reoperation rates did not differ significantly between patients in whom multi-level posterior fusions ended in the cervical spine versus those of which was extended into the thoracic spine. The mean blood loss, operative time and length of stay were significantly lower in patients with caudal level as C7 or below, compared to their counterparts. These data suggest that, absent focal C7-T1 pathology, extension of long posterior cervical fusions into the thoracic spine may not be necessary. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

In various surgical settings, single measures of frailty are increasingly used to guide patient selection and inform risk modification. Since a cardinal aspect of frailty is loss of functional capacity associated with loss of muscle mass, measures of sarcopenia have been looked to as indicators of frailty. Psoas muscle area (TPA) has emerged as a particularly practical and effective measure of sarcopenia. The present study aims to assess the utility of TPA as a predictor of perioperative morbidity and mortality. A retrospective review was conducted on 367 consecutive patients undergoing lumbar spinal surgery at our institution from January 2016 to February 2017. Demographic information was collected from review of the electronic medical record. Morphometric measurements including vertebral body area and right and left psoas muscle area were recorded by 2 independent readers at the mid-L3 level from MRI or CT within 1 year of index surgery. Outcomes included perioperative adverse events, rehospitalization within 90 days, and 90-day mortality. TPA and TPA indexed to vertebral area were calculated for all patients. The overall rate of perioperative complication was 26%, rate of rehospitalization within 90 days was 15%, and 90-day mortality was 0.8%. Age, sex, history of hypertension, hyperlipidemia, diabetes, and former or current smoking were not associated with the incidence of adverse events, rehospitalization or death. Surgical characteristics including fusion type and number of vertebral levels treated were also not significantly associated with morbidity or mortality. Both TPA and TPA indexed to vertebral area did not associate with perioperative adverse events, rehospitalization, or 90-day mortality in both univariate regression and multivariate regression adjusting for age and for sex. Only a history of prior lumbar surgery was significantly associated with perioperative complication (OR 1.67, CI 1.04-2.68, p=0.03). In an adult lumbar spine surgery population, morphometric measurements of TPA and TPA indexed to vertebral area were not associated with perioperative adverse event, rehospitalization, or mortality. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Understanding the timing of adverse event onset is a critical component of post-surgical care and discharge planning. As health-care systems continue to evolve toward rewarding quality of care through episode and bundled payments, spine surgeons face increasing pressure to minimize hospital length of stay following common yet costly procedures such as cervical laminoplasty. Although prior studies outline the incidence and predictors of postoperative complications following cervical laminoplasty, the time elapsed between surgery and adverse event onset remains unknown. PURPOSE To characterize the timing of postoperative complications following cervical laminoplasty. STUDY DESIGN/SETTING Retrospective cohort analysis using the 2012-2015 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. PATIENT SAMPLE The study included 1,243 patients undergoing cervical laminoplasty. OUTCOME MEASURES Outcome measures were rate and timing of postoperative complications, readmission, and reoperation. METHODS A retrospective cohort analysis of the NSQIP database for 2012-2015 was performed. Data from patients undergoing cervical laminoplasty was extracted with 12 outcomes selected a priori: stroke or CVA, MI,pneumonia, pulmonary embolism, UTI, deep vein thrombosis requiring therapy, sepsis, superficial SSI, deep SSI, organ space SSI, unplanned reoperation, and hospital readmission. Analysis was done to determine rate of adverse events, timing to adverse events, 30-day readmission rates and timing, and 30-day unplanned reoperation rates and timing. RESULTS A total of 1,243 patients undergoing cervical laminoplasty were identified for this study. The median day of diagnosis (lower quartile-upper quartile) for myocardial infarction was 2days (1–7 days), for pneumonia 4days (1–6 days), for pulmonary embolism 4days (3–13 days), for stroke or CVA 8 (4–14 days), unplanned reoperation 9.5 (4–16 days), urinary tract infection 10.5 (4–14.5 days), readmission 14 (6.5–18.5 days), deep incisional surgical site infection 16.5 (12–19 days), organ or space surgical site infection 18 (15–21 days), sepsis 18 (8–21 days), and superficial incisional surgical site infection 24 (20–26 days). CONCLUSIONS A value-based health-care system requires that physicians optimize patient outcomes while containing costs wherever possible. Decreasing postoperative length of stay has been a major focus of hospital systems and surgeons in their response to emerging alternative payment models. However, outcome-based reimbursement and penalties for hospital readmissions necessitate that surgeons not discharge a patient prematurely. The results of this study can help improve clinical decision-making by identifying the typical time frame during which adverse events develop following cervical laminoplasty. [ABSTRACT FROM AUTHOR]