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The objective of this study was to determine if Medicare status and age affect clinical outcomes following anterior cervical discectomy and fusion.Patients who underwent cervical discectomy and fusion between 2014 and 2020 with complete preoperative and 1-year postoperative patient-reported outcome measures (PROMs) were grouped based on Medicare status and age: no Medicare under 65 years (NM 65), Medicare under 65 years (M65), no Medicare 65 years or older (NM ≥ 65), and Medicare 65 years or older (M ≥ 65). Multivariate regression for ΔPROMs (Δ: postoperative minus preoperative) controlled for confounding differences between groups. Significant was set at P0.05.A total of 1288 patients were included, with each group improving in the visual analog score (VAS) Neck (all, P0.001), VAS Arm (M65: P = 0.003; remaining groups: P0.001), and Neck Disability Index (M65: P = 0.009; remaining groups: P0.001) following surgery. Only M65 did not significantly improve in the Physical Component Score (PCS-12) and modified Japanese Orthopaedic Association (mJOA) score (P = 0.256 and P = 0.092, respectively). When comparing patients under 65 years, non-Medicare patients had better preoperative PCS-12 (P0.001), Neck Disability Index (P 0.001), and modified Japanese Orthopaedic Association (P0.001), as well as better postoperative values for all PROMs (P0.001), but there were no differences in ΔPROMs. Multivariate analysis identified M65 to be an independent predictor of decreased improvement in ΔPCS-12 (β = -4.07, P = 0.015), ΔVAS Neck (β = 1.17, P = 0.010), and ΔVAS Arm (β = 1.15, P = 0.025) compared to NM 65.Regardless of age and Medicare status, all patients undergoing cervical discectomy and fusion had significant clinical improvement postoperatively. However, Medicare patients under age 65 have a smaller magnitude of improvement in PROMs.

Retrospective cohort.To determine if intraoperative on-table lumbar lordosis (LL) and segmental lordosis (SL) coincide with perioperative change in lordosis.Improvements in sagittal alignment are believed to correlate with improvements in clinical outcomes. Thus, it is important to establish whether intraoperative radiographs predict postoperative improvements in LL or SL.Electronic medical records were reviewed for patients ≥18 years old who underwent single-level and two-level anterior lumbar interbody fusion with posterior instrumentation between 2016 and 2020. LL, SL, and the lordosis distribution index were compared between preoperative, intraoperative, and postoperative radiographs using paired t tests. A linear regression determined the effect of subsidence on SL and LL.A total of 118 patients met inclusion criteria. Of those, 75 patients had one-level fusions and 43 had a two-level fusion. LL significantly increased following on-table positioning [delta (Δ): 5.7°, P0.001]. However, LL significantly decreased between the intraoperative to postoperative radiographs at two to six weeks (Δ: -3.4°, P =0.001), while no change was identified between the intraoperative and more than three-month postoperative radiographs (Δ: -1.6°, P =0.143). SL was found to significantly increase from the preoperative to intraoperative radiographs (Δ: 10.9°, P0.001), but it subsequently decreased at the two to six weeks follow up (Δ: -2.7, P0.001) and at the final follow up (Δ: -4.1, P0.001). On linear regression, cage subsidence/allograft resorption was predictive of the Δ SL (β=0.55; 95% confidence interval: 0.16-0.94; P =0.006), but not LL (β=0.10; 95% confidence interval: -0.44 to 0.65; P =0.708).Early postoperative radiographs may not accurately reflect the improvement in LL seen on intraoperative radiographic imaging, but they are predictive of long-term lumbar sagittal alignment. Each millimeter of cage subsidence or allograft resorption reduces SL by 0.55°, but subsidence does not significantly affect LL.4.

BACKGROUND: The presence of predominant pain in the arm vs the neck as a predictor of postoperative outcomes after anterior cervical discectomy and fusion (ACDF) has been seldom reported; therefore, the purpose of this study was to determine whether patients with predominant neck pain improve after surgery compared to patients with predominant arm pain or those with mixed symptoms in patients undergoing ACDF for radiculopathy. METHODS: A retrospective cohort study was conducted on patients who underwent ACDF at a single center from 2016 to 2018. Patients were split into groups based on preoperative neck and arm pain scores: neck (N) pain dominant group (visual analog scale [VAS] neck ≥ VAS arm by 1.0 point); neutral group (VAS neck < VAS arm by 1.0 point); or arm (A) pain dominant group (VAS arm ≥ VAS neck by 1.0 point), using a threshold difference of 1.0 point. Subsequently, individuals were substratified into 2 groups based on the arm to neck pain ratio (ANR): non-arm pain dominant defined as ANR ≤1.0 and arm pain dominant (APD) defined as ANR >1.0. Patient-reported outcome measurements including Neck Disability Index (NDI), Physical Component Score-12, and Mental Component Score (MCS-12) were compared between groups. RESULTS: No significant differences between groups when stratifying patients using a threshold difference of 1.0 point. When stratifying patients using the ANR, those in the APD group had significantly higher postoperative MCS-12 (P = 0.008) and NDI (P = 0.011) scores. In addition, the APD group showed a greater magnitude of improvement for MCS-12 and NDI scores (P = 0.043 and P = 0.038, respectively). Multiple linear regression showed that the A and the APD groups were both independent predictors of improvement in NDI. CONCLUSION: Patients with dominant arm pain showed significantly greater improvement in terms of MCS-12 and NDI scores compared to patients with dominant neck pain. CLINICAL RELEVANCE: To compare the impact of ACDF on arm and neck pain in the context of cervical radiculopathy using patient-reported outcome measures as an objective measurement. LEVEL OF EVIDENCE: 3.

STUDY DESIGN Retrospective study. OBJECTIVE To elucidate an association between preoperative lumbar epidural corticosteroid injections (ESI) and infection after lumbar spine surgery. SUMMARY OF BACKGROUND DATA ESI may provide diagnostic and therapeutic benefit; however, concern exists regarding whether preoperative ESI may increase risk of postoperative infection. METHODS Patients who underwent lumbar decompression alone or fusion procedures for radiculopathy or stenosis between 2000 and 2017 with 90 days follow-up were identified by ICD/CPT codes. Each cohort was categorized as no preoperative ESI, less than 30 days, 30 to 90 days, and greater than 90 days before surgery. The primary outcome measure was postoperative infection requiring reoperation within 90 days of index procedure. Demographic information including age, sex, body mass index (BMI), Charlson Comorbidity Index (CCI) was determined. Comparison and regression analysis was performed to determine an association between preoperative ESI exposure, demographics/comorbidities, and postoperative infection. RESULTS A total of 15,011 patients were included, 5108 underwent fusion and 9903 decompression only. The infection rate was 1.95% and 0.98%, among fusion and decompression patients, respectively. There was no association between infection and preoperative ESI exposure at any time point (1.0%, P = 0.853), ESI within 30 days (1.37%, P = 0.367), ESI within 30 to 90 days (0.63%, P = 0.257), or ESI > 90 days (1.3%, P = 0.277) before decompression surgery. There was increased risk of infection in those patients undergoing preoperative ESI before fusion compared to those without (2.68% vs. 1.69%, P = 0.025). There was also increased risk of infection with an ESI within 30 days of surgery (5.74%, P = 0.005) and when given > 90 days (2.9%, P = 0.022) before surgery. Regression analysis of all patients demonstrated that fusion (P

Study design Retrospective cohort study. Objective The aim of this study was to determine whether the presence of a fellow or resident (F/R) compared to a physician assistant (PA) affected surgical variables or short-term patient outcomes. Summary of background data Although orthopedic spine fellows and residents must participate in minimum number of decompression surgeries to gain competency, the impact of trainee presence on patient outcomes has not been assessed. Methods One hundred and seventy-one patients that underwent a one- to three-level lumbar spine decompression procedure at a high-volume academic center were retrospectively identified. Operative reports from all cases were examined and patients were placed into one of two groups based on whether the first assist was a F/R or a PA. Univariate analysis was used to compare differences in total surgery duration, 30-day and 90-day readmissions, infection and revision rates, patient-reported outcome measures (Short Form-12 Physical Component Score and Mental Component Score, Oswestry Disability Index, Visual Analog Scale [VAS] Back, VAS Leg) between groups. Multiple linear regression was used to assess change in each patient reported outcome and multiple binary logistic regression was used to determine significant predictors of revision, infection, and 30- or 90-day readmission. Results Seventy-eight patients were included in the F/R group compared to 93 patients in the PA group. There were no differences between groups for total surgery time, 30-day or 90-day readmissions, infection, or revision rates. Using univariate analysis, there were no differences between the two groups pre- or postoperatively (P > 0.05). Using multivariate analysis, presence of a surgical trainee did not significantly influence any patient reported outcome and did not affect infection, revision, or 30- and 90-day readmission rates. Conclusion This is one of the first studies to show that the presence of an orthopedic spine fellow or resident does not affect patient short-term outcomes in lumbar decompression surgery. Level of evidence 3.

Study design This was a prospective cohort study. Objective The objective of this study was to design and test a novel spine neurological examination adapted for telemedicine. Summary of background data Telemedicine is a rapidly evolving technology associated with numerous potential benefits for health care, especially in the modern era of value-based care. To date, no studies have assessed whether. Methods Twenty-one healthy controls and 20 patients with cervical or lumbar spinal disease (D) were prospectively enrolled. Each patient underwent a telemedicine neurological examination as well as a traditional in-person neurological examination administered by a fellowship trained spine surgeon and a physiatrist. Both the telemedicine and in-person tests consisted of motor, sensory, and special test components. Scores were compared via univariate analysis and secondary qualitative outcomes, including responses from a satisfaction survey, were obtained upon completion of the trial. Results Of the 20 patients in the D group, 9 patients had cervical disease and 11 patients had lumbar disease. Comparing healthy control with the D group, there were no significant differences with respect to all motor scores, most sensory scores, and all special tests. There was a high rate of satisfaction among the cohort with 92.7% of participants feeling "very satisfied" with the overall experience. Conclusions This study presents the development of a viable neurological spine examination adapted for telemedicine. The findings in this study suggest that patients have comparable motor, sensory, and special test scores with telemedicine as with a traditional in-person examination administered by an experienced clinician, as well as reporting a high rate of satisfaction among participants. To our knowledge, this is the first telemedicine neurological examination for spine surgery. Further studies are warranted to validate these findings.

Study Design: Retrospective cohort study. Objective: The goal of this study was to determine whether the absolute size (mm2), relative size (% canal compromise), or location of a single-level, lumbar disc herniation (LDH) on axial and sagittal cuts of magnetic resonance imaging (MRI) were predictive of eventual surgical intervention. Methods: MRIs of 89 patients were reviewed, and patients were split into groups based on type of management received (34 nonoperative vs 55 microdiscectomy). Radiographic characteristics—including size of disc herniation (mm2), size of spinal canal (mm2), location of herniation on axial (central, paracentral, foraminal) and sagittal (disc level, suprapedicle, pedicle, infrapedicle) planes, and type of herniation (bulge, protrusion, extrusion, sequestration)—were measured by 2 independent, orthopedic spine fellows and compared between groups via univariate and multivariate analyses. Results: The operative group showed a significantly higher percentage of canal compromise (39.5% vs 31.1%, P = .001) compared to the nonoperative group. Multiple logistic regression analysis showed higher odds of eventual operative intervention for a disc protrusion (odds ratio [OR] 6.30 [1.99, 19.86], P = .002) or disc extrusion (OR 11.5 [1.63, 81.2], P = .014) for Rater 1 and a higher odds of eventual surgical management for a paracentral location for both Rater 1 and Rater 2 (OR = 3.39 [1.25, 9.22], P = .017, and OR = 5.46 [1.77, 16.8], P = .003, respectively). Conclusions: Disc herniations in a paracentral location were more likely to undergo operative treatment than those more centrally located, on axial MRI views.

Study design A single center, observational prospective clinical study. Objective The aim of this study was to compare the instrumentation-related cost and efficiency of single-use instrumentation versus traditional reusable instrument trays. Summary of background data Single-use instrumentation provides the opportunity to reduce costs associated with cleaning and sterilizing instrumentation after surgery. Although previous studies have shown single-use instrumentation is effective in other orthopedic specialties, it is unclear if single-use instrumentation could provide economic advantages in spine surgery. Materials and methods A total of 40 (20 reusable instrumentation and 20 single-use instrumentation) lumbar decompression (1-3 level) and fusion (1 level) spine surgeries were collected. Instrument handling, opening, setup, re-stocking, cleaning, sterilization, inspection, packaging, and storage were recorded by direct observation for both reusable and single-use instrumentation. The rate of infection was noted for each group. Results Mean time of handling instruments by the scrub nurse was 11.6 (±3.9) minutes for reusable instrumentation and 2.1 (±0.5) minutes for single-use instrumentation. Mean cost of handling reusable instruments was estimated to be $8.52 (±$2.96) per case, and the average cost to reprocess a single tray by Sterilization Processing Department (SPD) was $58. Thus, the median cost for sterilizing 2 reusable trays per case was $116, resulting in an average total Costresuable of $124.52 (±$2.96). Mean cost of handling single-use instrumentation was estimated to be $1.57 ($0.38) per case. Conclusion Single-use instrumentation provided greater cost savings and reduced time from the opening of instrumentation to use in surgery when compared with reusable instrumentation.

Study Design: Retrospective cohort study. Objective: The goal of this study was to determine how smoking status influences patient-reported outcome measurements (PROMs) in patients undergoing lumbar decompression surgery. Methods: Patients undergoing lumbar decompression between 1 to 3 levels at a single-center, academic hospital were retrospectively identified. Patients Results: A total of 195 patients were included in the final cohort, with 121 (62.1%) patients in the NS group, 22 (11.3%) in the CS group, and 52 (26.6%) in the FS group. There were no significant differences between groups at baseline or postoperatively. Smoking status was also not a significant predictor of change in any outcome scores over time on multivariate analysis. Conclusion: These results suggest that smoking status does not significantly affect short-term complications or outcomes in patients undergoing lumbar decompression surgery.

This is a retrospective comparative review.The objective of this study was to identify the influence of body mass index (BMI) on postsurgical complications and patient reported outcomes measures (PROMs) following lumbar decompression surgery.Current literature does not accurately identify the impact of BMI on postsurgical complications or outcomes.Records from a single-center, academic hospital were used to identify patients undergoing 1 to 3-level lumbar decompression surgery. Patients under 18 years of age, those undergoing surgery for infection, trauma, tumor, or revision, and those with1-year follow-up were excluded. Patients were split into groups based on preoperative BMI: class I: BMI25.0 kg/m; class II: BMI 25.0-29.9 kg/m; class III: BMI 30.0-34.9 kg/m; and class IV: BMI35.0 kg/m. Absolute PROM scores, the recovery ratio and the percent of patients achieving minimum clinically important difference between groups were compared and a multiple linear regression analysis was performed.A total of 195 patients were included with 34 (17.4%) patients in group I, 80 (41.0%) in group II, 49 (25.1%) in group III, and 32 (16.5%) in group IV. Average age was 60.0 (58.0, 62.0) years and average follow-up was 13.0 (12.6, 13.4) months. All patients improved significantly within each group, except for class III and class IV patients, who did not demonstrate significant improvements in terms of Mental Component Score (MCS-12) scores (P=0.546 and 0.702, respectively). There were no significant differences between BMI groups for baseline or postoperative PROM values, recovery ratio, or the percent of patients reaching minimum clinically important difference. Multiple linear regression analysis revealed that BMI was not a significant predictor for change in outcomes for any measure. The 30-day readmission rate was 6.2% and overall revision rate at final follow-up was 5.1%, with no significant differences between groups.This study's results suggest that BMI may not significantly affect complications or patient outcomes at 1-year in those undergoing lumbar decompression surgery.Level III.

STUDY DESIGN Retrospective cohort review. OBJECTIVE The objective of this study was to identify depression using the Mental Component Score (MCS-12) of the Short Form-12 (SF-12) survey and to correlate with patient outcomes. SUMMARY OF BACKGROUND DATA The impact of preexisting depressive symptoms on health-care related quality of life (HRQOL) outcomes following lumbar spine fusion is not well understood. METHODS Patients undergoing lumbar fusion between one to three levels at a single center, academic hospital were retrospectively identified. Patients under the age of 18 years and those undergoing surgery for infection, trauma, tumor, or revision, and less than 1-year follow-up were excluded. Patients with depressive symptoms were identified using an existing clinical diagnosis or a score of MCS-12 less than or equal to 45.6 on the preoperative SF-12 survey. Absolute HRQOL scores, the recovery ratio (RR) and the percent of patients achieving minimum clinically important difference (MCID) between groups were compared, and a multiple linear regression analysis was performed. RESULTS A total of 391 patients were included in the total cohort, with 123 (31.5%) patients reporting symptoms of depression based on MCS-12 and 268 (68.5%) without these symptoms. The low MCS-12 group was found to have significantly worse preoperative Oswestry disability index (ODI), visual analogue scale back pain (VAS Back) and visual analogue scale leg pain (VAS Leg) scores, and postoperative SF-12 physical component score (PCS-12), ODI, VAS Back, and VAS Leg pain scores (P

Retrospective cohort study.To compare infection rates before and after the implementation of a quality improvement protocol focused on methicillin-resistant Staphylococcus aureus (MRSA) screening and decolonization in patients undergoing lumbar fusion and/or decompression.Prior studies have demonstrated MRSA infections comprise a sizable portion of SSIs. Additional studies are required to improve our understanding of the risks and benefits of MRSA decolonization with vancomycin prophylaxis.A retrospective cohort analysis was conducted on patients who underwent spinal fusion or laminectomy before (2008-2011) and after (2013-2016) the implementation of an MRSA screening and treatment protocol. Odds ratios for MRSA, methicillin-sensitive Staphylococcus aureus (MSSA), and Vancomycin-resistant Enterococcus (VRE) infection before and after screening was calculated. Multivariate analysis assessed demographic characteristics as potential independent predictors of infection.A total of 8425 lumbar fusion and 2558 lumbar decompression cases met inclusion criteria resulting in a total cohort of 10,983 patients. There was a significant decrease in the overall rate of infections (P0.001), MRSA infections (P0.001), and MSSA infections (P0.001) after protocol implementation. Although VRE infections after protocol implementation were not significantly different (P=0.066), VRE rates as a percentage of all postoperative infections were substantially increased (0 vs. 3.36%, P=0.007). On multivariate analysis, significant predictors of the infection included younger age (OR=0.94[0.92-0.95]), shorter length of procedure (OR=1.00[0.99-1.00]), spinal fusion (OR=18.56[8.22-53.28]), higher ASA class (OR=5.49[4.08-7.44]), male sex (OR=1.61[1.18-2.20]), and history of diabetes (OR=1.58[1.08-2.29]).The implemented quality improvement protocol demonstrated that preoperative prophylactically treating MRSA colonized patients decreased the rate of overall infections, MSSA infections, and MRSA infections. In addition, younger age, male sex, diabetic status, greater ASA scores, and spinal fusions were risk factors for postoperative infection.

Background: The present study intended to identify debris in the spine surgical field that frequently rises to the level of the surgeon9s face during several different elective spine procedures. Unlike other areas of orthopedic surgery where infection risk is of high concern, in spine surgery the surgical team usually uses a nonsterile face mask instead of a protective space suit with a sterile face shield. It is possible that blood or bone burr particles striking the surgeon9s face mask represent a potential source of infection if they ricochet back into the operative field. Methods: We reviewed 46 consecutive, elective spine surgeries between May 2015 and August 2015 from a single-surgeon practice. For each surgery, every member of the surgical team wore sterile (space suit) personal protective equipment. After each procedure, the face shield was carefully inspected by 2 members of the surgical team to identify patient blood, tissue, or bone burr dust present on the face shield. Results: The rate of surgeon face shield debris inspected for each case overall was 38/46 (83%). The rate of first assistant face shield debris inspected per case was 16/46 (35%). The scrub technician had a 0% rate of face mask debris on inspection. The highest debris exposure rates occurred with transforaminal lumbar interbody fusions (100%), open laminectomy and fusions (100%), and anterior cervical discectomy and fusions 43/46 (93%). Conclusions: There is a high rate of blood and tissue debris contact that occurs during spine surgery, and it is procedure dependent. Spine surgeons may consider using sterile shields particularly in high-risk cases to protect themselves and their patients. Level of Evidence: 4.

This was a retrospective cohort.The objective of this study was to determine if instrumentation across the cervicothoracic junction (CTJ) in elective multilevel posterior cervical decompression and fusion (PCF) is associated with improved patient-reported outcome measures (PROMs).Fusion across the CTJ may result in lower revision rates at the expense of prolonged operative duration. However, it is unclear whether constructs crossing the CTJ affect PROMs.Standard Query Language (SQL) identified patients with PROMs who underwent elective multilevel PCF (≥3 levels) at our institution. Patients were grouped based on anatomic construct: crossing the CTJ (crossed) versus not crossing the CTJ (noncrossed). Subgroup analysis compared constructs stopping at C7 or T1. Independent t tests and χ 2 tests were utilized for continuous and categorical data, respectively. Regression analysis controlled for baseline demographics. The α was set at 0.05.Of the 160 patients included, the crossed group (92, 57.5%) had significantly more levels fused (5.27 vs. 3.71, Plt;0.001), longer operative duration (196 vs. 161 min, P =0.003), greater estimated blood loss (242 vs. 160 mL, P =0.021), and a decreased revision rate (1.09% vs. 10.3%, P =0.011). Neither crossing the CTJ (vs. noncrossed) nor constructs spanning C3-T1 (vs. C3-C7) were independent predictors of ∆PROMs (change in preoperative minus postoperative patient-reported outcomes) on regression analysis. However, C3-C7 constructs had a greater revision rate than C3-T1 constructs (15.6% vs. 1.96%, P =0.030).Crossing the CTJ in patients undergoing elective multilevel PCF was not an independent predictor of improvement in PROMs at 1 year, but they experienced lower revision rates.Level III.

Although the Affordable Care Act (ACA) has been shown to broadly affect access to care, there is little data examining the change in insurance status with regard to nonelective spinal trauma, infection, and tumor patients. The purpose of this study is to evaluate the changes in insurance status before and after implementation of the ACA in patients who present to the emergency room of a single, level 1 trauma and regional spinal cord injury center. Patient demographic and hospital course information were derived from consult notes and electronic medical record review. Spinal consults between January 1, 2013, and December 31, 2015, were initially included. Consults between January 1 and December 31, 2014, were subsequently removed to obtain two separate cohorts reflecting one calendar year prior to ("pre-ACA") and following ("post-ACA") the effective date of implementation of the ACA on January 1, 2014. Compared with the pre-ACA cohort, the post-ACA cohort had a significant increase in insurance coverage (95.0% versus 83.9%, P0.001). Post-ACA consults had a significantly shorter length of stay compared with pre-ACA consults (7.94 versus 9.19, P0.001). A significantly greater percentage of the post-ACA cohort appeared for clinical follow-up subsequent to their initial consultation compared to the pre-ACA cohort (49.5% versus 35.3%, P0.001). Spinal consultation after the implementation of the ACA was found to be a significant positive predictor of Medicaid coverage (odds ratio = 1.96 [1.05, 3.82], P = 0.04) and a significant negative predictor of uninsured status (odds ratio = 0.28 [0.16, 0.47], P0.001). Increase in overall insurance coverage, increase in patient follow-up after initial consultation, and decrease in hospital length of stay were all noted after the implementation of the ACA for spinal consultation patients presenting to the emergency department.

This was a retrospective cohort study.The objective of this study was to compare radiographic and patient-reported outcome measures (PROMs) between circumferential fusions and transforaminal lumbar interbody fusion (TLIF) for adult isthmic spondylolisthesis (IS).Definitive management of adult IS typically requires decompression and fusion. Multiple fusion techniques have been described, but literature is sparse in identifying the optimal technique.Patients with IS undergoing single-level or 2-level circumferential fusion or TLIF with a minimum 1-year follow-up were included. Patient demographics, surgical characteristics, and PROMs were extracted from patients' electronic medical records. Descriptive statistics and multivariate regression analysis compared outcomes with significance set at P -valuelt;0.05.A total of 78 circumferential fusions (48 open decompression and fusions and 30 circumferential fusions utilizing posterior percutaneous instrumentation) and 50 TLIF procedures were included. Length of stay was significantly longer when comparing circumferential procedures (3.56±0.96 d) versus TLIFs (2.88±1.14 d) ( P =0.002). The circumferential fusion group resulted in greater postoperative improvement in segmental lordosis [anterior/posterior (A/P): 6.45, TLIF: -1.99, Plt;0.001], posterior disk height (A/P: 12.6 mm, TLIF: 8.9 mm, Plt;0.001), and ∆disk height (A/P: 7.7 mm, TLIF: 3.6 mm, Plt;0.001). Both groups significantly improved in all PROMs ( Plt;0.001). While the circumferential fusion group had a significantly higher rate of perioperative surgical complications (12.82% vs. 2.00%, P =0.049), there was no difference in the rate of 30-day readmissions ( P =0.520) or revision surgeries between techniques ( P =0.057).Circumferential fusions are associated with improvements in radiographic outcomes compared with TLIFs, but this is at the expense of longer hospital length of stay and increased risk for perioperative complications. The surgical technique did not result in superior postoperative PROMs or differences in readmissions or revisions.

STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of this study was to investigate the differences in Medicare reimbursement for one- to three-level lumbar decompression procedures performed at a tertiary referral center versus an orthopedic specialty hospital (OSH). SUMMARY OF BACKGROUND DATA Lumbar decompression surgery is one of the most commonly performed spinal procedures. Lumbar decompression also comprises the largest proportion of spinal surgery that has transitioned to the outpatient setting. METHODS Patients who underwent a primary one- to three- level lumbar decompression were retrospectively identified. Reimbursement data for a tertiary referral center and an OSH were compiled through Centers for Medicare and Medicaid Services. Demographic data, surgical characteristics, and time cost data were collected through chart review. Multivariate regression models were used to determine independent factors associated with total episode of care cost, operating room (OR) time, procedure time, and length of stay (LOS), and to determine independent predictors of having the decompression performed at the OSH. RESULTS Total episode of care, facility, and non-facility payments were significantly greater at the tertiary referral center than the OSH, as were OR time for one- to three-level procedures, procedure time of all pooled levels, and LOS for one- and two-level procedures. Three-level procedure was independently associated with increased OR time, procedure time, and LOS. Age and two-level procedure were also associated with increased LOS. Procedure at the OSH was associated with decreased OR time and LOS. Charlson Comorbidity Index was a negative predictor of decompression being performed in the OSH setting. CONCLUSION Significant financial savings to health systems can be expected when performing lumbar decompression surgery at a specialty hospital as opposed to a tertiary referral center. Patients who are appropriate candidates for surgery in an OSH can in turn expect faster perioperative times and shorter LOS.Level of Evidence: 3.

The purpose of this retrospective cohort study was to investigate the impact of smoking on patient-reported outcome measures (PROMs) following elective posterior cervical decompression and fusion (PCF).Electronic medical records at a single institution were reviewed for patients undergoing elective PCF. Patients were grouped based on smoking history: current smokers, former smokers, and never smokers. A delta score (Δ) was calculated for all PROMs (postoperative minus preoperative scores). Continuous and categorical data were compared using analysis of variance or χA total of 195 patients were included, of whom 35 (22.1%) were current smokers, 51 (26.2%) were former smokers, and 101 (51.8%) were never smokers. Preoperative and postoperative Short-Form 12 Mental Component Score (MCS-12) were significantly lower in the current smoker group (preoperative: current 42.7, former 49.9, and never 46.6; P = 0.024; postoperative: current 44.6, former 53.7, and never 52.2; P = 0.003). Only never smokers improved in MCS-12 and Neck Disability Index following surgery. On regrouping, current smokers had significantly lower preoperative MCS-12 (42.7 vs. 47.7, P = 0.031), lower preoperative modified Japanese Orthopaedic Association (12.2 vs. 14.0, P = 0.039), greater preoperative visual analog scale Arm (6.39 vs. 4.94, P = 0.025), and lower postoperative MCS-12 (44.6 vs. 52.7, P = 0.001). Only the nonsmokers improved in MCS-12 and Neck Disability Index following surgery. On regression analysis, smoking was not an independent predictor of ΔPROMs.Univariate analysis found that smokers have worse symptoms at baseline. However, smoking status was not an independent predictor of improvement in ΔPROMs following elective PCF.

Retrospective case-control study.To compare health-related quality of life outcomes at one-year follow-up between patients who did and did not develop surgical site infection (SSI) after thoracolumbar spinal fusion.SSI is among the most common healthcare-associated complications. As healthcare systems increasingly emphasize the value of delivered care, there is an increased need to understand the clinical impact of SSIs.A retrospective 3:1 (control:SSI) propensity-matched case-control study was conducted for adult patients who underwent thoracolumbar fusion from March 2014 to January 2020 at a single academic institution. Exclusion criteria included less than 18 years of age, incomplete preoperative and one-year postoperative patient-reported outcome measures, and revision surgery. Continuous and categorical data were compared via independent t tests and χ 2 tests, respectively. Intragroup analysis was performed using paired t tests. Regression analysis for ∆ patient-reported outcome measures (postoperative minus preoperative scores) controlled for demographics. The α was set at 0.05.A total of 140 patients (105 control, 35 SSI) were included in final analysis. The infections group had a higher rate of readmission (100% vs. 0.95%, P0.001) and revision surgery (28.6% vs. 12.4%, P =0.048). Both groups improved significantly in Physical Component Score (control: P =0.013, SSI: P =0.039), Oswestry Disability Index (control: P0.001, SSI: P =0.001), Visual Analog Scale (VAS) Back (both, P0.001), and VAS Leg (control: P0.001, SSI: P =0.030). Only the control group improved in Mental Component Score ( P0.001 vs. SSI: P =0.228), but history of a SSI did not affect one-year improvement in ∆MCS-12 ( P =0.455) on regression analysis. VAS Leg improved significantly less in the infection group (-1.87 vs. -3.59, P =0.039), which was not significant after regression analysis (β=1.75, P =0.050).Development of SSI after thoracolumbar fusion resulted in increased revision rates but did not influence patient improvement in one-year pain, functional disability, or physical and mental health status.

Investigations in spine surgery have demonstrated that trainee involvement correlates with increased surgical time, readmissions, and revision surgeries; however, the specific effects of spine fellow involvement remain unelucidated. This study aims to investigate the isolated effect of fellow involvement on surgical timing and patient-reported outcomes measures (PROMs) after spine surgery and evaluate how surgical outcomes differ by fellow experience.All patients aged 18 years or older who underwent primary or revision decompression or fusion for degenerative diseases and/or spinal deformity between 2017 and 2019 at a single academic institution were retrospectively identified. Patient demographics, surgical factors, intraoperative timing, transfusion status, length of stay (LOS), readmissions, revision rate, and preoperative and postoperative PROMs were recorded. Surgeries were divided based on spine fellow participation status and occurrence in the start or end of fellowship training. Univariate and multivariate analyses compared outcomes across fellow involvement and fellow experience groups.A total of 1,108 patients were included. Age, preoperative diagnoses, number of fusion levels, and surgical approach differed markedly by fellow involvement. Fellow training experience groups differed by patient smoking status, preoperative diagnosis, and surgical approach. On univariate analysis, spine fellow involvement was associated with extended total theater time, induction start to cut time, cut to close time, and LOS. Increased spine fellow training was associated with reduced cut to close time and LOS. On regression, fellow involvement predicted cut to close extension while increased fellow training experience predicted reduction in cut to close time, both independent of surgical factors and assisting residents or physician assistants. Transfusions, readmissions, revision rate, and PROMs did not differ markedly by fellow involvement or experience.Spine fellow participation predicted extended procedural duration. However, the presence of a spine fellow did not affect long-term postoperative outcomes. Furthermore, increased fellow training experience predicted decreased procedural time, underscoring a learning effect.The data sets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.Level 3.

Retrospective cohort study.The aim was to compare the outcomes of patients with incompletely corrected cervical deformity against those without deformity following short-segment anterior cervical decompression and fusion for clinically significant radiculopathy or myelopathy.Cervical deformity has increasingly been recognized as a driver of disability and has been linked to worse patient-reported outcomes measures (PROMs) after surgery.Patients 18 years or above who underwent 1-3 level anterior cervical decompression and fusion to address radiculopathy and/or myelopathy at a single institution between 2014 and 2018 with at least 1 year of PROMs were reviewed. Patients were categorized based on cervical deformity into 2 groups: sagittal vertebral axis (cSVA) ≥40 mm as the deformity group, and cSVA40 mm as the nondeformity group. Patient demographics, surgical parameters, preoperative and postoperative radiographs, and minimum 1-year PROMs were compared.Of the 230 patients, 191 (83%) were in the nondeformity group and 39 (17%) in the deformity group. Patients with deformity were more likely to be male (69.2% vs. 40.3%, P0.001) and have a greater body mass index (32.8 vs. 29.7, P=0.028). The deformity group had significantly greater postoperative cSVA (44.2 vs. 25.1 mm, P0.001) but also had significantly greater ∆cSVA (-4.87 vs. 0.25 mm, P=0.007) than the nondeformity group. Both groups had significant improvements in visual analog scale arm, visual analog scale neck, Short-Form 12 Physical Component Score, and neck disability index (NDI) (P0.001). However, the deformity group experienced significantly greater ∆NDI and ∆mental component score (MCS)-12 scores (-19.45 vs. -11.11, P=0.027 and 7.68 vs. 1.32, P=0.009).Patients with preoperative cervical sagittal deformity experienced relatively greater improvements in NDI and MCS-12 scores than those without preoperative deformity. These results suggest that complete correction of sagittal alignment is not required for patients to achieve significant clinical improvement.III.

This study aims to determine if preoperative weakness is an isolated risk factor for prolonged postoperative opioid use after anterior cervical discectomy and fusion (ACDF). Patients with preoperative weakness were significantly more likely to have prolonged and inappropriate opioid use and have a single prescription mean morphine equivalent (MME) ≥ 200. Logistic regression isolated preoperative weakness, opioid tolerance, depression, and VAS Neck pain as independent predictors of extended opioid use. High postoperative opioid dose (MME ≥ 90) correlated with opioid tolerance, younger age, male sex, greater CCI, prior cervical surgery, and preoperative VAS Neck pain on regression.

Background: While the impact of trainee involvement in other surgical fields is well established, there is a paucity of literature assessing this relationship in orthopaedic spine surgery. The goal of this study was to further elucidate this relationship. Methods: A retrospective cohort study was initiated on patients undergoing 1–3 level lumbar spine fusion at a single academic center. Operative reports from cases were examined, and patients were divided into 2 groups depending on whether a fellow or resident (F/R) or a physician9s assistant (PA) was used as the primary assist. Patients with less than 1-year follow-up were excluded. Multiple linear regression was used to assess change in each patient-reported outcome, and multiple binary logistic regression was used to determine significant predictors of revision, infection, and 30- or 90-day readmission. Results: One hundred and seventy-two patients were included in the F/R group compared with 178 patients in the PA group. No differences existed between groups for total surgery time, length of stay, 30- or 90-day readmissions, infection, or revision rates. No differences existed between groups in terms of patient-reported outcomes preoperatively or postoperatively. In addition, presence of a surgical trainee was not a significant predictor of patient outcomes or rates of infection, overall revision, or 30- and 90-day readmission rates. Conclusions: The results of this study indicate the presence of an orthopaedic spine F/R does not increase complication rates and does not affect short-term patient-reported outcomes in lumbar decompression and fusion surgery. Level of Evidence: 3.

STUDY DESIGN Health Services Research. OBJECTIVE The purpose of this study is to determine the variability of Medicaid (MCD) reimbursement for patients who require spine procedures, and to assess how this compares to regional Medicare (MCR) reimbursement as a marker of access to spine surgery. SUMMARY OF BACKGROUND DATA The current health care environment includes two major forms of government reimbursement: MCD and MCR, which are regulated and funded by the state and federal government, respectively. METHODS MCD reimbursement rates from each state were obtained for eight spine procedures, utilizing online web searches: anterior cervical decompression and fusion, posterior cervical decompression and fusion, posterior lumbar decompression, single-level posterior lumbar fusion, posterior fusion for deformity (less than six levels; six to 12 levels; 13+ levels), and lumbar microdiscectomy. Discrepancy in reimbursement for these procedures on a state-to-state basis, as well as overall differences in MCD versus MCR reimbursement, was determined. Procedures were examined to identify whether certain surgical interventions have greater discrepancy in reimbursement. RESULTS The average MCD reimbursement was 78.4% of that for MCR. However, there was significant variation between states (38.8%-140% of MCR for the combined eight procedures). On average, New York, New Jersey, Florida, and Rhode Island provided MCD reimbursements

STUDY DESIGN This was a retrospective cohort study. OBJECTIVE The goal of this study is to determine if skipping a single level affects the revision rate for patients undergoing multilevel posterior cervical decompression and fusion (PCDF). SUMMARY OF BACKGROUND DATA A multilevel PCDF is a common procedure for patients with cervical spondylotic myelopathy. With advanced pathology, it can be difficult to safely place screw instrumentation at every level increasing the risk of intraoperative and perioperative morbidity. It is unclear whether skipping a level during PCDF affects fusion and revision rates. PATIENTS AND METHODS A cervical spine surgeries database at a single institution was used to identify patients who underwent ≥3 levels of PCDF. Inclusion criteria consisted of patients who had screws placed at every level or if they had a single level without screws bilaterally. Patients were excluded if the surgery was performed for tumor, trauma, or infection, and age below 18 years, or if there was

Study design Retrospective review of a prospectively maintained database. Objective Compare outcomes following anterior cervical decompression and fusion (ACDF) between patients with no adjacent level spondylolisthesis (NAS) and adjacent level spondylolisthesis (AS). Summary of background data There are no prior studies evaluating the effect of preoperative adjacent-level cervical spondylolisthesis on outcomes following anterior cervical discectomy and fusion (ACDF). Methods A retrospective review of consecutive patients who underwent ACDF for degenerative cervical disease was performed. Adjacent level spondylolisthesis was defined on radiographs as anterior displacement (> 1 mm) of the vertebra in relation to an adjacent "to be fused" level. Patients were categorized as either AS or NAS. Preoperative and 1-year postoperative outcomes including Short Form-12 Physical and Mental Component Scores, Neck Disability Index, Visual Analog Score for arm and neck pain, and rate of revision surgery were compared between the two groups. Radiographic changes were also analyzed for patients with AS. Results A total of 264 patients met the inclusion criteria. There were 53 patients (20.1%) with AS and 211 patients (79.9%) with NAS. Both groups improved significantly from baseline with respect to all patient outcomes and there were no significant differences between the two groups. After accounting for confounding variables, the presence of an AS was not a predictor of any postoperative outcome. Revision rates did not differ between the two groups. Conclusion Patients with an AS had similar postoperative clinical outcomes compared with NAS. Furthermore, the presence of an AS was not a predictor of poorer clinical outcomes. This is the first study to investigate the effect of AS in patients undergoing ACDF and suggests that an adjacent-level spondylolisthesis does not need to be included in a fusion construct if it is not part of the primary symptom generating pathology. Level of evidence 3.

Study Design: Retrospective cohort review Objectives: Cervical pseudarthrosis is a frequent cause of need for revision anterior cervical discectomy and fusion (ACDF) and may lead to worse patient-reported outcomes. The effect of proton pump inhibitors on cervical fusion rates are unknown. The purpose of this study was to determine if patients taking PPIs have higher rates of nonunion after ACDF. Methods: A retrospective cohort review was performed to compare patients who were taking PPIs preoperatively with those not taking PPIs prior to ACDF. Patients younger than 18 years of age, those with less than 1-year follow-up, and those undergoing surgery for trauma, tumor, infection, or revision were excluded. The rates of clinically diagnosed pseudarthrosis and radiographic pseudarthrosis were compared between PPI groups. Patient outcomes, pseudarthrosis rates, and revision rates were compared between PPI groups using either multiple linear or logistic regression analysis, controlling for demographic and operative variables. Results: Out of 264 patients, 58 patients were in the PPI group and 206 were in the non-PPI group. A total of 23 (8.71%) patients were clinically diagnosed with pseudarthrosis with a significant difference between PPI and non-PPI groups ( P = .009). Using multiple linear regression, PPI use was not found to significantly affect any patient-reported outcome measure. However, based on logistic regression, PPI use was found to increase the odds of clinically diagnosed pseudarthrosis (odds ratio 3.552, P = .014). Additionally, clinically diagnosed pseudarthrosis negatively influenced improvement in PCS-12 scores ( P = .022). Conclusions: PPI use was found to be a significant predictor of clinically diagnosed pseudarthrosis following ACDF surgery. Furthermore, clinically diagnosed pseudarthrosis negatively influenced improvement in PCS-12 scores.