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Background: Several studies have demonstrated the utility of intraoperative neuromonitoring (IOM) including somatosensory evoked potentials (SSEPs), motor-evoked potentials (MEPs), and electromyography (EMG), in decreasing the risk of neurologic injury in spinal deformity procedures. However, there is limited evidence supporting the routine use of IOM in elective posterolateral lumbar fusion (PLF)., Methods: The National Inpatient Sample (NIS) was analyzed for the years 2012-2015 to identify patients undergoing elective PLF with (n=22,404) or without (n=111,168) IOM use. Statistical analyses were conducted to assess the impact of IOM on length of stay, total charges, and development of neurologic complications. These analyses controlled for age, gender, race, income percentile, primary expected payer, number of reported comorbidities, hospital teaching status, and hospital size., Results: The overall use of IOM in elective PLFs was found to have increased from 14.6% in the year 2012 to 19.3% in 2015. The total charge in hospitalization cost for all patients who received IOM increased from $129,384.72 in 2012 to $146,427.79 in 2015. Overall, the total charge of hospitalization was 11% greater in the IOM group when compared to those patients that did not have IOM (P<0.001). IOM did not have a statistically significant impact on the likelihood of developing a neurological complication., Conclusions: While there may conceivably be benefits to the use of this technology in complex revision fusions or pathologies, we found no meaningful benefit of its application to single-level index PLF for degenerative spine disease., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jss-20-679). The authors have no conflicts of interest to declare., (2021 Journal of Spine Surgery. All rights reserved.)

With a great interest, we read the article by Neidenbach et al. on non-cardiac comorbidities in German adults with congenital heart disease (ACHD). ACHD always bear an increased risk of developing concomitant non-cardiac comorbidities and complications and impose a great healthcare burden. Limited large-scale data from the United States (US) on this focus incited us to write this brief report. Gilboa et al. estimated nearly 2.4 million people living with CHD (1.4 million adults, 1 million children) in the US in 2010. To have a better nationwide prospect of the current scenario, we looked at the extra-cardiac comorbidities among ACHD patients hospitalized in the US using the National Inpatient Sample database (NIS) for years 2013-2014. The burden of extracardiac comorbidities among the NIS cohort in the US was diverse as compared to the German outpatient ACHD cohort. Our study reports a higher burden of endocrinological, hematological, metabolic, pulmonary, psychiatric, renal and rheumatological comorbidities as compared to the German cohort. However, the burden of gastrointestinal and hepatological comorbidities was higher in the German outpatient cohort. In addition, ACHD patients with non-cardiac comorbidities were older except for those suffering from the psychiatric illnesses as compared to ACHD hospitalizations without comorbidities. It is imperative for the clinicians to understand the non-cardiac complications which a patient might encounter during a lifetime, and which could further complicate the management of ACHD and increases the risk of mortality., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Objective: Patients with colorectal carcinoma (CRC) with pre-existing chronic liver disease (CLD) had a significantly higher 30-day mortality after CRC surgery compared with healthy controls. This study investigated the factors associated with postoperative complications and in-hospital mortality in patients with CRC with coexisting CLD (excluding cirrhosis) who underwent colorectal surgery., Design: A retrospective, observational, population-based study., Setting: Data were sourced from the National Inpatient Sample database, a part of the Healthcare Cost and Utilisation Project., Participants: This study analysed 7463 inpatients with CRC who underwent colorectal surgery on admission between 2005 and 2014., Primary and Secondary Outcome Measures: The primary endpoint of this study was the prevalence of postoperative complications, and the secondary endpoint was in-hospital mortality., Results: In the CLD group, 36.27% of patients had chronic hepatitis C, 28.36% had non-alcoholic fatty liver disease and 31.19% had other types of CLD. The median hospital stay was 7.0 (5.0-10.0) days in patients with no postoperative complications vs 17.0 (10.0-26.0) days, 8.0 (6.0-12.0) days, 8.0 (6.0-17.0) days, 9.0 (8.0-14.0) days and 10.5 (7.0-17.0) days for patients with postoperative infection, postoperative bleeding, cardiac arrest/heart failure, respiratory complications and digestive complications, respectively (all p<0.05). The presence of CLD was significantly associated with higher risk of postoperative bleeding (adjusted OR (aOR)=1.64, 95% CI 1.15 to 2.34, p=0.007). The presence of CLD (aOR=1.98, 95% CI 1.39 to 2.82, p<0.001) and length of hospital stay (aOR=1.06, 95% CI 1.04 to 1.08, p<0.001) were significantly associated with higher risk of in-hospital mortality. However, hyperlipidaemia was associated with a significantly lower risk of mortality (aOR=0.46, 95% CI 0.28 to 0.75, p=0.002)., Conclusions: Postoperative complications prolonged the length of hospital stay. The presence of CLD and hyperlipidaemia were important factors impacting postoperative complications and in-hospital mortality in patients with CRC with underlying CLD., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: To identify temporal changes to the demographics and utilization of intraoperative neuromonitoring (IONM) throughout the United States (U.S.)., Methods: The National Inpatient Sample (NIS) database was queried for IONM of central and peripheral nervous electrical activity (ICD-9-CM 00.94) between 2008 and 2014. The NIS database represents a 20% sample of discharges from U.S. Hospitals, weighted to provide national estimates. Demographic and economic data were obtained which included the annual number of surgeries, age, sex, insurance type, location, and frequency of routine discharge., Results: The estimated use of IONM of central and peripheral nervous electrical activity increased 296%, from 31,762 cases in 2008 to 125,835 cases in 2014. Based on payer type, privately insured patients (45.0%), rather than Medicare (36.8%) or Medicaid patients (9.2%), were more likely to undergo IONM during spinal procedures. When stratifying by median income for patient zip code, there was a substantial difference in the rates of IONM between low (19.9%) and high-income groups (78.1%). IONM was significantly more likely to be utilized at urban teaching hospitals (72.9%) rather than nonteaching hospitals (25.0%) or rural centers (2.2%)., Conclusions: Over the last decade, there has been a massive increase of 296% in utilization of IONM during spine surgery. This is likely due to its proven benefit in reducing neurologic morbidity in spinal deformity surgery, while introducing minimal additional risk. While IONM may improve patient care, it is still rather isolated to teaching hospitals and patients from higher income zip codes., Competing Interests: Conflicts of Interest: Dr. Ronald A. Lehman reports grants from PRORP (Department of Defense Peer Reviewed Orthopaedic Research Program), personal fees and non-financial support from DePuy Synthes Spine, personal fees and non-financial support from Stryker, and personal fees and non-financial support from Medtronic outside the submitted work. Dr. Lawrence G. Lenke reports Board Membership from OREF and GSO, personal fees from Consultancy—DePuy Synthes Spine, K2M, Medtronic, personal fees from Expert Testimony—Fox Rothschild, LLP, grants from AO Spine, Scoliosis Research Society, DePuy Synthes Spine, Setting Scoliosis Straight Foundation, EOS, Royalties from Medtronic and Quality Medical Publishing, patent from Medtronic, personal fees from Travel accommodations/meeting expenses—AO Spine, Broadwater, Seattle Science Foundation, Scoliosis Research Society, The Spinal Research Foundation, grants from Fellowship Grant—AO Spine, North America, and grants from Philanthropic research funding. The other authors have no conflicts of interest to declare.

Study Design: Retrospective database study., Objectives: Analysis of economic and demographic data concerning interspinous device (ID) placement throughout the United States to improve value-based care and health care utilization., Methods: The National Inpatient Sample (NIS) database was queried for patients who underwent insertion of an interspinous process spinal stabilization device (ICD-9-CM 84.80) between 2008 and 2014 across 44 states. Demographic and economic data were obtained which included the annual number of surgeries, age, sex, insurance type, location, and frequency of routine discharge. The NIS database represents a 20% sample of discharges from US hospitals, which is weighted to provide national estimates., Results: There was a 73% decrease in ID implanted from 2008 to 2014. The mean cost associated with insertion of the device increased 28% from $13 653 in 2008 to $17 515 in 2014. The mean length of stay (LOS) increased from 1.8 to 2.4 days. Patients aged 45 to 64 years increased from 14.1% to 34.3% while patients aged 65 to 84 years decreased from 74.4% to 60.6%. By region, 34% of ID placement occurred in the South followed by 19.7% that occured in the Northeast. When stratifying by median income for patient zip code, the procedure was performed more in cities designated as higher rather than lower income areas (74.2% and 19.5%, respectively)., Conclusions: Throughout the United States, there was a progressive decline in the insertion of interspinous spacers by 73% over the study period. The total costs for the procedure increased by 28% while the aggregate national charges decreased by 55.6% between 2008 and 2014., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Ronald A. Lehman Jr reports grants from PRORP (Department of Defense Peer Reviewed Orthopaedic Research Program), personal fees and nonfinancial support from DePuy Synthes Spine, personal fees and nonfinancial support from Stryker, personal fees and nonfinancial support from Medtronics outside the submitted work. Dr Lawrence Lenke reports unpaid positions from Board Membership OREF and GSO, personal fees from Consultancy–DePuy Synthes Spine, K2M, Medtronic, personal fees from Expert Testimony–Fox Rothschild, LLP, grants from AO Spine; Scoliosis Research Society; DePuy Synthes Spine; Setting Scoliosis Straight Foundation; EOS, Royalties from Patents–Medtronic, personal fees from Travel accommodations/meeting expenses–AOSpine, Broadwater, Seattle Science Foundation, Scoliosis Research Society, The Spinal Research Foundation, grants from Fellowship Grant–AOSpine, North America, grants from Philanthropic research funding outside the submitted work. No other authors report potential conflicts of interest.

Background: The purpose of this study was to examine outcomes of robotic ventral hernia repair(RVHR) versus laparoscopic ventral hernia repair(LVHR)., Methods: The Nationwide Inpatient Sample was queried from October 2008 to December 2013 for ventral hernia repairs. Demographics, morbidity, mortality, and charges were compared between RVHR and LVHR., Results: From 2008-2013, 149,622 ventral hernia surgeries were identified; 117,028 open, 32,243 laparoscopic, and 351 robotic. Open repairs were excluded. RVHR rose annually with 2013 containing 47.9% of all RVHRs. RVHR patients were more likely to be older and have more chronic conditions. There was no difference between length of stay. Pneumonia rates were higher with RVHR; however, after controlling for confounding variables, there was no difference in pneumonia rates. Mortality and other major complications were similar. Total charges were increased for RVHR in univariate and multivariate analysis. RVHR was more common in teaching hospitals and wealthier zip codes., Conclusion: RVHR demonstrates comparable safety to the laparoscopic technique, with increased charges and increased volume in urban teaching hospitals and patients from areas of higher median income., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Given the increasing societal focus on health care utilization and value-based care, it is essential to understand the demographic and economic data surrounding percutaneous vertebral augmentation procedures performed in the United States. Double-blinded prospective randomized controlled trials have shown no benefit to the use of vertebroplasty over a sham procedure in the treatment of vertebral fractures. Contrastingly, kyphoplasty may be beneficial when appropriately indicated., Methods: The National Inpatient Sample (NIS) database was queried for patients who underwent either kyphoplasty (ICD-9-CM 81.66) or vertebroplasty (ICD-9-CM 81.65) procedures between 2006 and 2014 across 44 states. Demographic and economic data were obtained which included the annual number of surgeries, age, sex, insurance type, location, and frequency of routine discharge. The NIS database represents a 20% sample of discharges from U.S. hospitals, which is weighted to provide national estimates., Results: In 2014, an estimated total number of 19,420 kyphoplasty and 6,130 vertebroplasty procedures were performed across the United States. The number of vertebroplasty procedures decreased 53% from 13,128 in 2008. Similarly, the number of kyphoplasty procedures decreased 17% from 23,320 in 2007. Based on payer, Medicare patients comprised 83% of those billed for kyphoplasty and vertebroplasty, and 75% of procedures were utilized in areas designated as "not low income". In 2014, patients in the South Atlantic region comprised 24% of vertebroplasty and 28% of kyphoplasty cases, far more than any other region. Additionally, kyphoplasty and vertebroplasty were more often performed in teaching facilities rather than community hospitals (60% and 67%, respectively)., Conclusions: Since the publication of two double-blind, prospective randomized controlled trials showed no benefit of vertebroplasty over a sham procedure, there has been a significant decrease in both kyphoplasty and vertebroplasty procedures., Competing Interests: Conflicts of Interest: SC Ludwig, MD reports the following disclosures—AO Spine North America Spine Fellowship Support (Research support); ASIP, ISD (Stock or stock options); Cervical Spine Research Society (Board or committee member); DePuy, A Johnson & Johnson Company (IP royalties; Paid consultant; Paid presenter or speaker); Globus Medical (Paid consultant; Research support); Journal of Spinal Disorders and Techniques, The Spine Journal, Contemporary Spine Surgery (Editorial or governing board); K2Medical (Paid consultant, Research support); Synthes (Paid consultant; Paid presenter or speaker); Thieme, QMP (Publishing royalties, financial or material support). LG Lenke, MD reports the following disclosures—Board Membership in OREF and GSO; Personal fees from Consultancy-DePuy Synthes Spine, K2M, and Medtronic; Personal fees from Expert Testimony-Fox Rothschild, LLP; Grants from AO Spine, Scoliosis Research Society, DePuy Synthes Spine, Setting Scoliosis Straight Foundation, EOS; Royalties from Patents-Medtronic; Personal fees from Travel accommodations/meeting expenses-AOSpine, Broadwater, Seattle Science Foundation, Scoliosis Research Society, The Spinl Research Foundation; Other grants from Fellowship Grant-AOSpine, North America, and grants from Philanthropic research funding outside the submitted work. RA Lehman, MD reports the following disclosures—Grants from PRORP (Department of Defense Peer Reviewed Orthopaedic Research Program); Personal fees and non-financial support from DePuy Synthes Spine; Personal fees and non-financial support from Stryker; Personal fees and non-financial support from Medtronic. The other authors have no conflicts of interest to declare.

Study Design: Analysis of Nationwide Inpatient Sample (NIS)., Objective: Evaluate evolution of operative treatment of adolescent idiopathic scoliosis (AIS)., Summary of Background Data: Spinal surgery is one of the most rapidly evolving branches of surgery. Changes in AIS operations are incompletely defined., Methods: Children (10-18 years) with ICD-9 diagnosis of idiopathic scoliosis who underwent thoracic and/or lumbar spinal fusion identified in the NIS (1998-2011) were analyzed. Population-based utilization rates were calculated from US Census data. Patient demographics, surgical approach, operative techniques, complications during hospitalization, hospital stay length, and charges were analyzed., Results: 60,108 children (46,256 girls, 13,776 boys, 76 gender not specified; average age 14.1 years) were identified. Thoracic fusions were the majority. Number of operations increased over time. For thoracic fusions, posterior operations significantly increased, whereas anterior and anterior/posterior operations decreased significantly. Although anterior operations for lumbar fusions declined, this was not as steep as thoracic. Use of autogenous bone graft (including iliac crest) significantly increased, which mirrored significant decreases in alternative fusion agents. Thoracoplasty significantly decreased, whereas osteotomy significantly increased. The average complication rate was 3.7%. Rates of blood transfusions, infection, and neural injury did not differ significantly from 1998 to 2011. Device-related complications increased significantly over time. Average lengths of hospital stay decreased significantly, whereas average total hospital charges increased significantly., Conclusions: In a representative sample of the US population from 1998 to 2011, operative approaches and techniques for AIS significantly changed. Anterior procedure is rarely performed for thoracic curves; lumbar curves continue to be treated with anterior and posterior approaches. Osteotomy and autogenous bone graft increased, while thoracoplasty decreased. Overall complication rates remain stable, whereas hospital lengths of stays decreased and charges increased., (Copyright © 2016 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)