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BACKGROUND CONTEXT Anterior cervical discectomy and fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), and hybrids (combination ACCF-ACDF) are common procedures used to treat symptomatic cervical spondylosis. Although there is a relative abundance of literature comparing 1-level ACCF vs 2-level ACDF and 2-level ACCF vs 3-level ACDF, detailed comparisons of 3-level ACDF vs hybrid procedures have not been extensively addressed. PURPOSE The objective of this study is to compare 3 and 12-month radiographic sagittal parameters and patient reported outcomes (PROs) in patients who underwent 3-level ACDF or a hybrid procedure. STUDY DESIGN/SETTING Longitudinal observational comparative cohorts from a large, multisurgeon database. PATIENT SAMPLE Patients who underwent a 3-level ACDF (3L-ACDF, N=47) or 1-level corpectomy/1-level ACDF (Hybrid, N=52) with at least a 12-month postop data available were identified. OUTCOME MEASURES EuroQOL-5D (EQ-5D), Neck Disability Index (NDI), neck and arm pain. Methods Standard demographic, surgical and (PROs) were collected in addition to pre- and postoperative radiographic data including C2 plumb line (C2PL), C2-C7 lordosis (CL), segmental lordosis (SL), and T1 slope (T1S). Results The two cohorts were similar in terms of demographics at baseline. At 3 months postop, CL (9.04°vs -2.12°, p=0.00) and SL (6.06°vs -2.26°, p=0.003) were significantly greater in the 3L-ACDF group versus the HYBRID group. This significant difference was maintained at 12 months postop for CL (6.62°vs -0.60°, p=0.015) but not for SL (2.36°vs -1.09°, p=0.199). There were no differences in PROs between the two groups prior to surgery, at 3 months postop, or at 12 months postop. Seven patients required revision surgery in the 1-year study period (1 in the 3L-ACDF, and 6 in the Hybrid p Conclusions Three-level ACDF resulted in greater C2-C7 lordosis and segmental lordosis postoperatively, which was maintained at 1 year for cervical lordosis. While patient reported outcomes were similar between the groups, patients with hybrid instrumentation required significantly more revision surgeries than those treated with 3-level ACDF. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Study Design: Longitudinal cohort study. Objectives: To investigate whether a cutoff point in leg pain intensity measured preoperatively or at early follow-up could identify patients at risk of poor outcomes in terms of disability at 1-year and 2-year follow-up after first-time lumbar discectomy, and to identify the characteristics associated with early postoperative leg pain intensity. Methods: From 2010 to 2013, 556 patients underwent lumbar discectomy. Leg pain intensity was measured preoperatively and at early postoperative follow-up and dichotomized according to an established cutoff point on a 0 to 100 visual analogue scale (mild Results: Moderate/severe leg pain intensity at early follow-up showed a statistically significant association with higher ODI at 1-year and 2-year follow-up compared to mild leg pain intensity (median [interquartile range]: 24 [26] and 26 [26] versus 12 [18] and 10 [20], respectively). Patients reporting moderate/severe leg pain intensity were more often smokers, were more prone to receive social benefits, and were more prone to have chronic back pain. The preoperative measurement of leg pain intensity showed inferior associations. Conclusion: The proposed cutoff point in leg pain intensity at early follow-up can identify patients at risk of disability at both 1-year and 2-year follow-up after first-time discectomy. Future research should be undertaken to investigate whether patients with moderate/severe leg pain intensity at early postoperative follow-up could benefit from additional or more intensive postoperative interventions.

STUDY DESIGN Longitudinal cohort. OBJECTIVES The aim of this study was to examine the relationship between patient satisfaction, patient-reported outcome measures (PROMs) and radiographic parameters in adult spine deformity (ASD) patients undergoing three-column osteotomies (3CO). SUMMARY OF BACKGROUND DATA Identifying factors that influence patient satisfaction in ASD is important. Evidence suggests Scoliosis Research Society-22R (SRS-22R) Self-Image domain correlates with patient satisfaction in patients with ASD. METHODS This is a retrospective review of ASD patients enrolled in a prospective, multicenter database undergoing a 3CO with complete SRS-22R pre-op and minimum 2-years postop. Spearman correlations were used to evaluate associations between the 2-year SRS Satisfaction score and changes in SRS-22R domain scores, Oswestry Disability Index (ODI), and radiographic parameters. RESULTS Of 135 patients eligible for 2-year follow-up, 98 patients (73%) had complete pre- and 2-year postop data. The cohort was mostly female (69%) with mean BMI of 29.7 kg/m2 and age of 61.0 years. Mean levels fused was 12.9 with estimated blood loss of 2695 cc and OR time of 407 minutes; 27% were revision surgeries. There was a statistically significant improvement between pre- and 2-year post-op PROMs and all radiographic parameters except Coronal Vertical Axis. The majority of patients had an SRS Satisfaction score of ≥3.0 (90%) or ≥4.0 (68%), consistent with a moderate ceiling effect. Correlations of patient satisfaction was significant for Pain (0.43, P

Background Recent work has shed light on the potential benefits of cannabinoids for multimodal pain control following orthopedic procedures. The objective of this review was to summarize the available evidence of analgesic and opioid-sparing effects cannabinoids have in orthopedic surgery and identify adverse events associated with their use. Methods A systematic review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines including PubMed, EMBASE, MEDLINE, PsycINFO, and Google Scholar was performed to include all primary, therapeutic studies published on the use of cannabis, and cannabis-derived products in orthopedic surgery. Results The literature review returned 4292 citations. Thirteen publications were found to meet inclusion criteria. Four randomized controlled trials were evaluated while the remaining studies were of quasi-experimental design. Conclusion Research on cannabinoids in orthopedic surgery is mostly of a quasi-experimental nature and is mainly derived from studies where orthopedics was not the primary focus. The overall results demonstrate potential usefulness of cannabinoids as adjunctive analgesics and in mitigating opioid use. However, the current evidence is far from convincing. There is a need to produce rigorous evidence with well-designed randomized controlled trials specific to orthopedic surgery to further establish these effects.

STUDY DESIGN Multicenter retrospective study. OBJECTIVE Flexion-extension radiographs are frequently used to assess motion in patients with degenerative spondylolisthesis. However, they expose patients to additional radiation and increase cost. The aim of this study is to determine if flexion-extension radiographs provide additional information not seen on upright neutral radiographs and supine magnetic resonance imaging (MRI) that may guide surgical decision making. SUMMARY OF BACKGROUND DATA Supine MRI and upright neutral radiographs are routinely performed in patients with degenerative spondylolisthesis. It is unclear whether additional flexion-extension views play a significant role in surgical planning for this patient population. METHODS From the Quality Outcomes Database, patients who had surgery for grade 1 degenerative spondylolisthesis were identified. Magnitude of slip on pre-op supine MRI, upright neutral, flexion, and extension radiographs were measured. Additional motion was defined as 3 mm or more slip difference between radiographs. For the purpose of this analysis, patients with a slip of 7 mm or more on upright neutral radiographs were assumed to require a fusion. RESULTS A total of 191 patients were identified. Mean age was 61.6 years (114 females, 60%). Only 31 patients (16%) had additional motion on flexion-extension views not seen on upright neutral x-rays versus supine MRI. Of these 31 patients, 19 had slips less than 7 mm on upright x-ray, generating equipoise for fusion. CONCLUSION Flexion-extension radiographs may play a limited role in management of degenerative spondylolisthesis. The subset of patients for which flexion-extension views were most likely to provide value were patients with smaller slips (

Retrospective multicenter cost analysis.To (1) determine if index episode of care (iEOC) costs of Adult Spinal Deformity (ASD) surgeries are below the Medicare Allowable (MA) threshold, and (2) identify variables that can predict iEOC cases that are below MA. Previous studies have suggested that actual direct hospital cost of Adult Spinal Deformity (ASD) surgery is higher than Medicare Allowable (MA) rates, which has become the benchmark reimbursement target for hospital accounting systems.From a prospective, multicenter ASD surgical database, patients undergoing long instrumented fusions ( 5 level) with cost data were identified. iEOC cost was calculated utilizing actual direct hospital cost. MA rates were calculated using hospital specific, year-appropriate CMS Inpatient Pricer Payment System. Recursive partitioning identified potentially modifiable variables that can predict iEOC cost MA.Administrative direct cost data from 210 patients were obtained from 4 of 11 centers. Ninety-five (45%) patients had iEOC cost MA. There was significant variation across the four centers in both iEOC cost ($56,788-$78,878, p 0.0001) and reimbursement ($40,623-$91,351, p 0.0001) across deformity-specific DRGs (453,454,456,457). Academic centers were more likely to have iEOC costs MA (67.2% vs 8.9%, p 0.0001). Recursive partitioning (rThere is significant institutional (private vs academic) variation in ASD reimbursement. BMP use, deformity type, approach, and baseline mental health impact ASD surgery cost being below Medicare reimbursement. ASD surgeries with anterior/posterior approaches are in DRGs that can potentially reimburse 2.2-fold the posterior-only surgery, making it more likely to fall below the MA threshold.III.

Study Design: Retrospective analysis of prospectively collected data. Objective: To identify modifiable factors associated with successful return to work 12 weeks following discectomy. Lumbar disc herniation is a common cause of sciatica and sick leave. This presents an economic burden to the individual and the society. Methods: Data from DaneSpine on a consecutive cohort of patients operated due to lumbar disc herniation during a 3-year period was identified and merged with data from the Ministry of Employment’s register on public welfare payments. Data on welfare payments 2 years prior to the date of operation and 1 year postoperative was included. Patients were considered to be on sick leave if they received welfare payments for the week. Patients are considered to have returned to work if they did not receive public welfare payments for a 4-week period. Results: Of 1134 patients meeting inclusion criteria, 98.5% had complete preoperative surgical data available. Postoperatively, 79.1% of the patients returned to the work within 12 weeks. Physically demanding jobs, low preoperative EQ5D score, and long duration of sick leave prior to surgery were associated negatively with return to work at 12 weeks. Conclusion: The results of this study indicate that patients who have a longer duration of sick leave have a physically demanding job and are in a poor health are more likely not to return to work by 12 weeks after surgery for lumbar disc herniation. Future studies are needed to determine if earlier referral to a surgeon leads to an earlier return to work.

Retrospective chart review.To determine if the addition of an anterior lumbar interbody fusion (ALIF) improves the fractional curve in adult spinal deformity correction when compared to posterior surgery alone. ALIF is commonly advocated to improve lordosis and fusion in adult deformity surgery. Improved fractional curve correction may help level the pelvis and minimize proximal malalignment.Patients undergoing thoracolumbar fusion to the pelvis with S2AI screws for deformity were identified and stratified into patients who had an ALIF as part of their deformity correction procedure (ALIF + PSF), and those who had a posterior approach alone. The posterior approach (PSF) includes patients who had a posterolateral fusion with or without a transforaminal lumbar interbody fusion (TLIF). Radiographic parameters measured included pre-op and post-op fractional coronal curve Cobb angle, lumbar lordosis, pelvic tilt, pelvic incidence and sacral slope, major Cobb angle, coronal and sagittal SVA.There were 31 cases in the ALIF + PSF group and 28 in the PSF group. Baseline demographic characteristics of the two groups were similar. Mean pre-op fractional coronal Cobb (18.3° vs 13.4°, p = 0.027) was larger in the ALIF + PSF group, whereas lumbar lordosis (31.0° vs 33.6°, p = 0.487) and pelvic parameters were similar between the two groups. Post-op lumbar lordosis was similar (48.2° vs 43.0°, p = 0.092). Greater fractional coronal curve correction was achieved in the ALIF + PSF group (67%) compared to the PSF group (36%) with a smaller post-op fractional coronal curve in the ALIF + PSF group (6.1°) compared to the PSF group (8.6°, p = 0.053).There is a greater correction of the fractional curve in the ALIF + PSF group compared with the PSF group. While this may not be the primary indication for ALIF, it is a benefit which may facilitate overall deformity correction and leveling of the pelvis.

Hyperkyphosis, including Scheuermann and postural kyphosis, is associated with decreased perceived cosmesis and well being. No patient reported outcome questionnaire specific to kyphosis exists. We sought to assess the internal consistency, test-retest reliability and concurrent validity of a new Kyphosis-specific Spinal Appearance Questionnaire (K-SAQ).A K-SAQ was developed from a modified SAQ to measure kyphosis-specific aspects of appearance. Patients with hyperkyphosis (ages 10-20 years) curves ≥ 50° completed the K-SAQ and SRS-22R at baseline and the K-SAQ 2 weeks later.55 patients completed the K-SAQ and SRS-22R. 28 patients completed the K-SAQ 2 weeks later. The K-SAQ total averages showed excellent internal consistency (Cronbach's α = 0.91) and test-retest reliability (ICC = 0.84). Moderate associations were seen between the SRS-22R subtotal average score and K-SAQ total average score and (r = - 0.62, p 0.001) and the SRS-22R self-image domain with the K-SAQ total average score (r = - 0.57, p 0.001). Higher BMI and increased age scored worse on the K-SAQ total average, whereas only higher BMI scored worse on the SRS-22R subtotal average.The K-SAQ is a reliable patient reported outcome measure of kyphosis-specific aspects of appearance.

Study Design: Longitudinal cohort. Objective: It is unclear if patients with a recurrent disc herniation benefit from a concurrent fusion compared with a repeat decompression alone. We compared outcomes of decompression alone (D0) versus decompression and fusion (DF) for recurrent disc herniation. Methods: Patients enrolled in the Quality and Outcomes Database from 3 sites with a first episode of recurrent disc herniation were identified. Demographic, surgical, and radiographic data including the presence of listhesis and extent of facet resection on computed tomography or magnetic resonance imaging prior to the index surgery were collected. Patient-reported outcomes were collected preoperatively and at 3 and 12 months postoperatively. Results: Of 94 cases identified, 55 had D0 and 39 had DF. Patients were similar in age, sex distribution, smoking status, body mass index, American Society of Anesthesiologists grade and surgical levels. Presence of listhesis (D0 = 7, DF = 5, P = .800) and extent of facet resection (D0 = 19%, DF = 16%, P = .309) prior to index surgery were similar between the 2 groups. Estimated blood loss (D0 = 26 cm3, DF = 329 cm3, P < .001), operating room time (D0 = 79 minutes, DF = 241 minutes, P < .001) and length of stay (D0 Conclusion: For a first episode recurrent disc herniation, surgeons can expect similar outcomes whether patients are treated with decompression alone or decompression and fusion.

OBJECTIVEThe aim of this study was to examine whether routine referral to municipal postoperative rehabilitation is cost-effective in comparison to no referral after surgery for lumbar disc herniation (LDH).METHODSOne hundred forty-six patients scheduled for primary discectomy due to LDH were included. This secondary analysis, based on data from a previous randomized controlled trial, compared costs and quality-adjusted life years (QALYs) between two groups of patients recovering from LDH surgery: one group of patients received a referral for municipal physical rehabilitation (REHAB) and the other group was sent home without a referral to any postoperative rehabilitation (HOME). Primary outcomes were QALYs calculated from the EQ-5D utility score, societal costs, and incremental cost-effectiveness ratios (ICERs). The main cost-effectiveness analysis used intention-to-treat data, whereas sensitivity analyses included as-treated data. Questionnaires were collected after 1, 3, 6, 12, and 24 months postoperatively.RESULTSThe main cost-effectiveness analysis showed a small, insignificant incremental QALY of 0.021 and an incremental cost of €211.8 for the REHAB group compared to the HOME group, resulting in an ICER of €10,085. In the as-treated sensitivity analysis, the REHAB group had poorer outcomes and higher costs compared to the HOME group.CONCLUSIONSRoutine referral to municipal physical rehabilitation in patients recovering from LDH surgery was not cost-effective compared to no referral.Clinical trial registration no.: NCT03505918 (clinicaltrials.gov)

Background context: Coccydynia is a painful condition which may severely impair quality of life in affected patients. Treatment of coccydynia is a field of interest with limited knowledge. The objective of this study is to evaluate the efficacy of current available treatments for coccydynia in adults, by systematically reviewing existing original peer-reviewed publications according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Methods/design: A systematic literature search will be conducted in EMBASE.com, PubMed.com, Scopus and Web of Science bibliographic databases from their inception to January 17th, 2020, alongside a search for published studies and Epubs ahead of print in journals with relevance to spine surgery. Studies eligible for inclusion are original peer-reviewed papers addressing treatment of chronic coccydynia in adults. The articles will be screened by two authors independently, involving a third author in case of disagreement. Quality assessment and data extraction will be conducted using Covidence software. A meta-analysis will be conducted given that data is suitable. Discussion: This systematic review and meta-analysis may contribute to the existing knowledge on the efficacy of treatment options for coccydynia. Systematic review registration: PROSPERO submission-ID: 166379 Keywords: Coccydynia, Pain, Treatment, Efficacy

Study Design Longitudinal cohort. Objective To report on the prevalence and indications for unplanned reoperations following index surgery in the Adult Symptomatic Lumbar Scoliosis NIH-sponsored Clinical Trial. Summary of Background Data Reoperation following adult spinal deformity surgery exposes the patient to additional surgical risk, increases the cost of care, and decreases the potential cost-effectiveness of the intervention. Accurate data regarding the prevalence and indication for reoperation will facilitate future efforts to minimize risk. Methods A total of 153 patients underwent adult spinal deformity surgery as part of the observational, randomized, or crossover groups and were eligible for two-year follow-up. Reoperations were meticulously tracked as part of the National Institutes of Health (NIH)–mandated serious adverse event (SAE) reporting. The primary indication for reoperation was obtained from the treating surgeon’s operative report. Results Thirty-two patients had one reoperation, two patients underwent two reoperations, and three patients underwent three reoperations. A total of 45 reoperations were performed in 37 patients. Eleven patients (7%) underwent reoperation within 90 days of the index surgery: two for superficial wound dehiscence, three for radiculopathy with screw removal, and six for acute proximal junctional failure (PJF). Four patients underwent reoperation for PJF more than 90 days from index surgery. Twenty-six patients underwent 28 reoperations for rod fracture/pseudoarthrosis. Conclusion In a consecutive series of adult spinal deformity surgery patients with meticulous follow-up, 24% of patients required an unplanned reoperation. The most common indication for reoperation was rod fracture/pseudoarthrosis, which occurred from 9 months to 3.7 years following the index surgery and accounted for 62% (28/45) of the reoperations. The second most common indication for reoperation was PJF, which occurred from 1 month to 1.6 years following index surgery and accounted for 22% (10/45) of the reoperations. As these complications will likely increase with longer follow-up, efforts to lower the rates of these complications are warranted. Level of Evidence Level II.

Study design Analysis of a prospective multicenter database. Objective To assess the ability of the recently created Adult Spinal Deformity (ASD) Frailty Index (ASD-FI) to predict odds of major complications and length of hospital stay for patients who had more severe preoperative deformity and underwent more invasive ASD surgery compared with patients in the database used to create the index. Summary of background data Accurate preoperative estimates of risk are necessary given the high complication rates currently associated with ASD surgery. Methods Patients were enrolled by participating institutions in Europe, Asia, and North America from 2009 to 2011. ASD-FI scores were used to classify 267 patients as not frail (NF) ( 0.5). Multivariable logistic regression, adjusted for preoperative and surgical covariates such as operative time and blood loss, was performed to determine the relationship between ASD-FI category and incidence of major complications, overall incidence of complications, and length of hospital stay. Results The mean ASD-FI score was 0.3 (range, 0-0.7). We categorized 105 patients as NF, 103 as frail, and 59 as SF. The adjusted odds of developing a major complication were higher for SF patients (odds ratio = 4.4; 95% CI 2.0, 9.9) compared with NF patients. After adjusting for covariates, length of hospital stay for SF patients increased by 19% (95% CI 1.4%, 39%) compared with NF patients. The odds of developing a major complication or having increased length of stay were similar between frail and NF patients. Conclusion Greater patient frailty, as measured by the ASD-FI, is associated with a longer hospital stay and greater risk of major complications among patients who have severe preoperative deformity and undergo invasive surgical procedures. Level of evidence 2.

Study Design: Longitudinal comparative cohort. Objectives: To determine if the duration of symptoms in patients with degenerative spondylolisthesis affects postoperative outcomes after 1- or 2-level decompression and fusion. Methods: Patients undergoing primary surgery for grade 1 degenerative spondylolisthesis at a single Quality Outcomes Database (QOD) participating site were identified. Demographic, surgical and patient-reported outcomes (PROs) data, including baseline and 12-month postoperative Oswestry Disability Index (ODI), back pain (BP, 0-10), leg pain (LP, 0-10), and EuroQOL-5D (EQ-5D) scores were collected. Individual medical records were reviewed for data on duration of symptoms prior to surgery. Patients were stratified into 3 cohorts—those with preoperative symptom duration of less than 1 year, 1 to 2 years, or greater than 2 years. Results: Complete data was available in 123 patients. Significant improvement in ODI, BP, and LP scores were observed in all groups. At 12-month follow-up improvement in ODI, BP, or LP was similar among the cohorts; with a trend toward significance with better improvement in LP scores in patients with a symptom duration of less than 1 year to those with symptom duration greater than 2 years ( P = .058). Conclusions: The duration of symptoms up to 2 years prior to surgery may not be a useful predictor of improvement of back pain or disability scores in patients with spondylolisthesis requiring decompression and fusion. Although there was a positive trend for improvement in leg pain for those with a shorter duration of symptoms, this did not reach statistical significance in our study.

Background Context Although lumbar disc herniation (LDH) classically presents with lower extremity radiculopathy, there are patients who have substantial associated back pain. Purpose The present study aims to determine if patients with LDH with substantial back pain improve with decompression alone. Study Design This is a longitudinal observational cohort study. Patient Sample Patients enrolled in the Quality and Outcomes Database with LDH and a baseline back pain score of ≥5 of 10 who underwent single- or two-level lumbar discectomy only. Outcome Measures Back and leg pain scores (0–10), Oswestry Disability Index (ODI), and EuroQoL 5D were measured. Methods Standard demographic and surgical variables were collected, as well as patient-reported outcomes at baseline and at 3 and 12 months postoperatively. Results The mean age of the cohort was 49.8 years and 1,195 (52.8%) were male. Mean body mass index was 30.1 kg/m2. About half of the patients (1,103, 48.8%) underwent single-level discectomy and the other half (1,159, 51.2%) had two-level discectomy. Average blood loss was 44 cc. Most of the patients (2,217, 98%) were discharged home with routine postoperative care. The average length of stay was 0.53 days. At 3 and 12 months postoperatively, there were statistically significant (p Conclusions Patients with LDH who have substantial back pain can be counseled to expect improvement in their back pain scores 12 months after a discectomy.

Background: Anterior cervical discectomy and fusion (ACDF) for cervical degenerative disease is an accepted treatment for symptomatic cervical radiculopathy and myelopathy. One- and two-level fusions are much more common and more widely studied. Outcomes and revision rates for three- and four-level ACDF have not been well described. The purpose of this study is to report on clinical outcomes and revision rates following multilevel ACDF. Methods: Patients who underwent three- or four-level anterior cervical discectomy with plate fixation between 2006 and 2011 from a single-center multi-surgeon practice for symptomatic cervical degenerative disease were identified. Improvements in neck disability index (NDI), neck and arm pain scores two years after surgery and revision rates were analyzed. Results: Forty-six patients with a mean age of 55.9 years were included in the analysis. Twenty-one (46%) were male, 10 (22%) were smokers. Forty-one (89%) underwent three-level fusion and 5 (11%) underwent four-level fusion. NDI improved from 34.46 at baseline to 25.47 at two years. Neck pain improved from 7.04 at baseline to 3.95 and arm pain improved from 6.24 to 3.09 at two year follow up. Sixteen patients (35%) returned to surgery within two years with 11 of these patients (24%) returning for non-union. The average number of days to revision surgery was 750.6±570.3 days. Conclusions: Patients undergoing three- and four-level ACDF for multilevel cervical disease demonstrate substantial improvement in outcomes. However, the two-year revision rate is relatively high at 35% with the majority of these patients returning due to non-union.

Background Scoliosis in patients with neurofibromatosis type I (NF1) can manifest as dystrophic or nondystrophic curves. Dystrophic scoliosis is rapidly progressive, rendering treatment challenging. Radiographic characteristics have been reported to predict dystrophic scoliosis, but their reliability and predictive value have not been well described. The purpose of this study is to assess the interobserver reliability for eight radiographic characteristics of dystrophic scoliosis and to evaluate the sensitivity and specificity of these characteristics relative to the gold standard of a definitive clinical diagnosis. Methods Spine radiographs of 122 NF1 patients from multiple institutions were graded by five spine surgeons as dystrophic or nondystrophic, based on eight radiographic characteristics of dystrophic modulation: rib penciling, vertebral rotation, scalloping, wedging, spindling of transverse processes, short sharp angular curve, widened interpedicular distance, and atypical location. The curves were classified by each submitting institution as dystrophic or nondystrophic based on clinical outcome. Interobserver reliability analysis was performed using Fleiss kappa. Results For the 122 cases, the interrater agreement among the five readers for the diagnosis of dystrophic scoliosis was good at 0.61. The agreement for individual radiographic characteristic ranged from 0.62 for wedging to 0.14 (poor) for scalloping. Surgeons underestimated the number of dystrophic curves, rating from 45% to 67% of the curve patterns as dystrophic, compared to the gold standard, which revealed 68% of the curves to be dystrophic. On multivariate analysis, rib penciling, vertebral rotation, vertebral wedging, and atypical location were significantly associated with true dystrophic status (odds ratios of 2.4, 3.0, 2.4, and 3.0, respectively). Conclusion Overall dystrophic diagnosis can be assessed by radiographic characteristics. Better understanding of the predictive value of specific radiographic features may assist in early diagnosis of patients with dystrophic NF and assist surgeons in identifying dystrophic curve patterns and instituting prompt, appropriate treatment. Level of evidence Level III.

Ethnic differences in spino-pelvic parameters among a healthy population are poorly defined in the literature. The purpose of this study was to document sagittal spino-pelvic parameters in a sample of African Americans and to compare them with previously reported data for Caucasians and Asians. African American individuals without spine pathology who had standing lateral radiographs were identified. Radiographs were measured to determine the following parameters: lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS). Data of adult subjects were compared with those previously published for Caucasians (n = 709) and Asians (n = 312). These measurements (LL, PI, PT, and SS) obtained for the 36 African American subjects aged 18 years or older [15 men and 21 women; mean age 26.6 ± 8.7 range (18–53)] The mean LL, PI, PT and SS values were 57.2°, 57.7°, 15.9° and 41.4°, respectively. A comparative analysis showed the means values for PI was greater in the African American than in Caucasian (57.7° vs. 52.6°, p = 0.007), and than in Asian (57.7° vs. 48.7°, p

OBJECTIVEFull-length (36-inch) standing spine radiographs are commonly used by spine surgeons to evaluate patients with lumbar degenerative scoliosis (LDS). Despite this practice, the impact of these images on preoperative decision making and the rate of revision surgery has not been analyzed. The purpose of this study is to determine if preoperative full-length standing spine radiographs improve surgical decision making by decreasing the rate of revision surgery in patients with LDS.METHODSFrom the Health Care Service Corporation administrative claims database, the authors identified patients 50–80 years of age with LDS who had undergone surgery including posterior lumbar decompression and fusion over 2–6 levels and with at least 5 years of continuous coverage after the index surgery. Patients were stratified into the following groups, according to the preoperative imaging studies performed within 6 months before their index surgery: lumbar spine MRI studies only, lumbar spine MRI studies and standard lumbar spine radiographs, CT myelograms, and full-length standing spine radiographs. Survival analysis was performed with the occurrence of a revision within 5 years of the index surgery as the outcome of interest.RESULTSA total of 411 patients were included in the study after applying the inclusion and exclusion criteria. Revision surgery within 5 years after the index procedure was most frequent in the patients with preoperative MRI only (41.8%), followed by the patients with a CT myelogram (30.4%) and those with MRI and standard radiographs (24.8%). The lowest revision rate was seen among those with long-cassette standing radiographs (11.1%). Patients whose preoperative evaluation included full-length standing radiographs (OR 0.353, p = 0.034) and MRI studies plus radiographs (OR 0.650, p = 0.022) were less likely to require revision surgery at 5 years after the index procedure.CONCLUSIONSAn assessment of standing alignment using full-length (36-inch) standing radiographs may be beneficial in reducing the risk of revision surgery in patients with lumbar scoliosis. This observation was not limited to patients with large curves or substantial deformity.

Author(s): Lenke, Lawrence G; Shaffrey, Christopher I; Carreon, Leah Y; Cheung, Kenneth MC; Dahl, Benny T; Fehlings, Michael G; Ames, Christopher P; Boachie-Adjei, Oheneba; Dekutoski, Mark B; Kebaish, Khaled M; Lewis, Stephen J; Matsuyama, Yukihiro; Mehdian, Hossein; Pellise, Ferran; Qiu, Yong; Schwab, Frank J; AO Spine International and SRS Scoli-RISK-1 Study Group | Abstract: BACKGROUND:The reported neurologic complication rate following surgery for complex adult spinal deformity (ASD) is variable due to several factors. Most series have been retrospective with heterogeneous patient populations and use of nonuniform neurologic assessments. The aim of this study was to prospectively document lower extremity motor function by means of the American Spinal Injury Association (ASIA) lower extremity motor score (LEMS) before and through 2 years after surgical correction of complex ASD. METHODS:The Scoli-RISK-1 study enrolled 272 patients with ASD, from 15 centers, who had undergone primary or revision surgery for a major Cobb angle of ≥80°, corrective osteotomy for congenital spinal deformity or as a revision procedure for any type of deformity, and/or a complex 3-column osteotomy. RESULTS:One of 272 patients lacked preoperative data and was excluded from the analysis, and 62 (22.9%) of the remaining 271 patients, who were included, lacked a 2-year postoperative assessment. Patients with no preoperative motor impairment (normal LEMS group; n = 203) had a small but significant decline from the mean preoperative LEMS value (50) to that at 2 years postoperatively (49.66 [95% confidence interval = 49.46 to 49.85]; p = 0.002). Patients who did have a motor deficit preoperatively (n = 68; mean LEMS, 43.79) had significant LEMS improvement at 6 months (47.21, p l 0.001) and 2 years (46.12, p = 0.003) postoperatively. The overall percentage of patients (in both groups combined) who had a postoperative LEMS decline, compared with the preoperative value, was 23.0% at discharge, 17.1% at 6 weeks, 9.9% at 6 months, and 10.0% at 2 years. CONCLUSIONS:The percentage of patients who had a LEMS decline (compared with the preoperative score) after undergoing complex spinal reconstructive surgery for ASD was 23.0% at discharge, which improved to 10.0% at 2 years postoperatively. These rates are higher than previously reported, which we concluded was due to the prospective, strict nature of the LEMS testing of patients with these challenging deformities. LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Study Design: Retrospective cohort study. Objectives: It is estimated that 10 000 patients seek medical care due to cervical radiculopathy every year in Denmark. Although the natural course is usually favorable, around 20% undergo surgery for cervical degenerative disease every year in Denmark. We aim to evaluate the patient-reported results and satisfaction of anterior cervical decompression and fusion over a 5-year period from a single Danish center for spine surgery. Methods: This study is a retrospective study based on prospectively collected data from 318 consecutive patients treated with anterior cervical decompression and fusion over 1 to 3 levels. Data in the DaneSpine registry was collected pre- and postoperatively, and at 1 year after surgery. The outcome measures were Neck Disability Index (NDI), European Quality of Life 5D (EQ-5D), visual analogue score (VAS), and Short Form-36 Physical Component Summary (SF-36 PCS). Results: Of 318 cases enrolled, 272 (85.5%) had follow-up data available at a minimum 1-year postoperatively. The mean preoperative NDI was 40.0 and improved to 22.7. Mean EQ-5D was 0.50 and improved to 0.70, and mean VAS arm was 60.4 improved to 26.4. All improvements were statistically significant. A total of 74.3% were back to work 1 year after surgery. Achieving minimal clinically important difference (MCID) in VAS neck and SF-36 PCS was strongly correlated to patient satisfaction. Conclusion: Patients who undergo anterior cervical discectomy and fusion can expect improvement in their pain and disability, with 74.3% of patients reporting a positive change in health status after surgery.

Longitudinal cohort.To investigate whether patients with painful adolescent idiopathic scoliosis experience pain relief with surgical treatment.Adolescent idiopathic scoliosis (AIS) was previously thought to be a painless condition, but recent studies have shown that a significant proportion of patients have pain. Little information is available regarding pain relief with surgical treatment for AIS.Patients enrolled in a prospective database of surgically treated AIS were divided into two groups based on their preoperative Scoliosis Research Society (SRS)-22R pain domain score. Patients with a preoperative pain domain score of 4 or more (N = 1005) were classified as nonpainful. If the preoperative pain domain score was less than 4 (N = 505), they were classified as painful. Demographics, SRS total and domain scores, and changes with treatment were compared for the two groups.The two groups had similar demographics and preoperative coronal curve magnitude. Patients with painful scoliosis experienced significant improvement in SRS-22R pain scores, from 3.29 preoperatively to 4.03 postoperatively (P 0.000). Eighty-one percent of these patients reached the minimum clinically important difference threshold (0.20) for improvement in pain score. Painful scoliosis patients also had greater 2-year improvement in total and all domain scores than the nonpainful scoliosis patients (P 0.000). Absolute values of SRS-22R total and domain scores were all greater at 2 years in the nonpainful group than the painful group.Patients with AIS with substantial back pain can be cautiously counseled to expect significant improvement in pain level with surgical correction of their deformity, even if curve progression is the primary indication for surgery. Although these patients achieve greater improvements in health-related quality of life compared with patients with mild or no pain, 2-year SRS-22R scores were still better in patients with mild or no pain preoperatively.2.

The Scoliosis Research Society-22r (SRS-22r) has been shown to be reliable, valid and responsive to change in patients with adult spinal deformity (ASD) undergoing surgery. The minimum clinically important difference (MCID) quantifies a threshold value of improvement that is clinically relevant to the patient. Health-related quality of life scores depend on age. The purpose of this study was to assess MCID threshold values stratified by age for SRS-22r domains in patients with ASD undergoing surgical correction.We identified a consecutive series of 184 Japanese ASD patients who completed the SRS-22r and Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) preoperatively and 1 year postoperatively. Effectiveness as measured on the JOABPEQ was used as the anchor to determine MCID for the Function, Pain, and Mental health domains using receiver-operating-characteristic (ROC) curve analysis. We performed MCID analysis stratified by age (70 or ≥70).Mean preoperative SRS-22r Function score was 2.69 improving to 3.23 at postoperatively (p 0.001). Mean preoperative SRS-22r Pain score was 3.04 improving to 3.78 at postoperatively (p 0.001). Mean preoperative SRS-22r Mental health score was 2.72 improving to 3.25 at postoperatively (p 0.001). There was a statistically difference in change in domain score between "not effective" and "effective" (p 0.001). The ROC curve analysis methods yielded MCID values of 0.58 for Function, 0.55 for Pain, and 0.70 for Mental health domains. There was difference of MCID value for Function and Mental health domain between aged70 and ≥70; 0.78 and 0.55 for Function; 0.70 and 0.48 for Mental health.Results of this study showed that MCID threshold values for SRS-22 Function and Mental health domains in older than 70 was lower than in younger than 70, potentially implying that older patients have lower expectation.

Retrospective cohort.To examine Charlson Comorbidity Index (CCMI) as a marker for deterioration in health status not reflected in standard Health Related Quality of Life (HRQOL) measures.HRQOL has become a primary metric for assessing outcomes following spinal deformity surgery. However, studies have reported limited impact of complications on postoperative HRQOL outcomes.We examined serial CCMI, complications, and HRQOL outcomes for 138 adult lumbar deformity patients treated surgically with a minimum two-year follow-up that included 126 females (91%) with a mean age of 59.8 years (range, 40.2-78.5). Patients with no, minor, or major complications were compared at baseline and at one and two years postoperation.Minor complications were observed in 26 patients (19%) and major complications in 15 (11%). Major complications included motor deficit (7), deep vein thrombosis (4), and respiratory failure (3). There was no difference in preoperative SF-36 Physical Component Summary or Scoliosis Research Society-22R (SRS-22R) scores among the groups at baseline. Preoperative CCMI was lowest in the No Complication group (3.52 ± 1.70) followed by the Major (4.00 ± 1.13) and Minor Complication groups (4.15 ± 1.71, p = .165). At one year, there was a significantly greater CCMI deterioration in the Major Complication group (0.80 ± 1.01) compared to both the Minor (0.08 ± 0.27) and No Complication groups (0.27 ± 0.47, p.001). There was no significant difference in SF-36 Physical Component Summary or SRS-22R scores among the three groups. Similar findings were observed at two years.Despite similar one- and two-year HRQOL improvement, patients with major complications had greater deterioration in CCMI. As CCMI is predictive of medical and surgical risk, patients who sustained a major complication now carry a greater likelihood of adverse outcomes with future interventions, including any subsequent spinal surgery. Although this increased risk may not alter the patient's perception of his or her current health status, it may be important, and should be recognized as part of the shared decision-making process.Level II, high-quality prognostic study.

BACKGROUND CONTEXT In patients with lumbar spinal stenosis, it is crucial for clinicians to identify all symptomatic levels. Prior studies have demonstrated that CT-myelography has a greater sensitivity in revealing stenosis (94.4%) compared to MRI (75.9%). CT-myelograms demonstrate weight-bearing changes as opposed to single position and single time point changes on MRI. However, CT-myelography is invasive, requiring injection of contrast dye into the thecal sac. PURPOSE The purpose of this study is to identify patients in whom additional levels of stenosis are likely to be recognized by a CT-myelogram following an MRI scan. STUDY DESIGN/SETTING Retrospective observational cohort at a single multi-surgeon spine center. PATIENT SAMPLE Patients ≥45 years old who had an MRI followed by a CT-myelogram within 6 months with a diagnosis of stenosis, spondylolisthesis, or degenerative scoliosis. OUTCOME MEASURES Additional levels of moderate to severe stenosis identified on CT-myelogram vs MRI. METHODS Medical records were reviewed to collect standard demographic and surgical data and to note if patients were deemed to have single-level or multi-level stenosis clinically. MRIs and CT-Myelograms obtained within six months of each other were reviewed and each lumbar level was recorded as mild, moderate, or severe based on the radiologist's report. Fisher's exact test was performed with change in recorded level of stenosis from MRI to CT-Myelogram as the primary outcome of interest. Results Of 207 patients, 139 (67%) had clinically reported multilevel stenosis and 68 (33%) had single-level stenosis. CT-Myelogram identified a greater proportion of additional stenotic levels in patients with clinically reported multilevel stenosis (80/139, 58%) compared to patients with single-level stenosis (27/68, 40%, p=0.018). When classifying patients based on MRI findings of stenosis instead of clinical diagnosis, 90 (43%) patients had multi-level stenosis, and 117 (56%) had single-level stenosis. In patients with radiologist-reported multilevel stenosis, CT-myelogram also identified a greater proportion of additional stenotic levels (55/90, 61%) compared to patients with radiologist-reported single level stenosis (52/117, 44%, p=0.025). Conclusions CT myelography is significantly more likely to provide valuable additional information in patients with multilevel stenosis as compared to patients with single level stenosis. This finding was consistent regardless of whether the distinction of single-level or multilevel stenosis was determined by clinical diagnosis or based solely off the MRI report. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT There continues to be a search for an ideal bone graft substitute that leads to improved fusion rates compared to autograft that has little to no known adverse effects. One of the latest bone graft substitutes is ABM/P-15. The RCT showed that there was a fusion rate of 50% in the ABM/P-15 group and 20% in the Allograft group. PURPOSE The purpose of this study is to report on the complications and reoperations in patients enrolled in a randomized controlled trial comparing ABM/P-15 to Allograft in un-instrumented fusion due to lumbar degenerative spondylolisthesis. STUDY DESIGN/SETTING Randomized controlled trial with 6 years follow-up. PATIENT SAMPLE Of 101 patients enrolled in a randomized controlled trial comparing ABM/P-15 to Allograft, 59 patients were available at 6 years postoperative, 30 in the ABM/P-15 group and 29 in the Allograft groups. OUTCOME MEASURES Any complication reported by the patient or identified during the patient's postoperative visit, including changes seen on radiographic imaging; and reoperations. METHODS Randomized controlled trial comparing ABM/P-15 vs allograft with a minimum of 6 years follow-up. RESULTS Of the 101 patients who were included in the RCT, 9 patients had wound complications during admission, 3 in the AMB/P15 group and 6 in the allograft group (p=0.254). One patient in each group had a superficial wound infection which required antibiotic treatment. Twenty-one patients had a reoperation during the 6 years follow-up, 12 in the Allograft group and 9 in the ABM/P15 group (p=0.331). Of the 59 patients available for 6-year follow-up, no osteolysis in the vertebrae was seen in any CT scan at 6 years after surgery. One patient in the ABM/P15 had a calcified hematoma, and one patient had bone migrating ventral from the transverse process into the psoas muscle. Both patients were asymptomatic. CONCLUSIONS Complication and reoperation rates were similar in patients treated with ABM/P15 compared to allograft. FDA DEVICE/DRUG STATUS ABM/P-15 (Not approved for this indication)

BACKGROUND CONTEXT A recent administrative database (PearlDiver) study reported increased 30-day complications with the utilization of robotic-assisted (RA) enabling technology. The authors reported increased fixation-related complications (3%) and infection rates (19%) in RA surgeries. Although there is ample evidence regarding improved pedicle screw accuracy with RA surgery, the complication profile has been called into question. PURPOSE The objective of the study is to compare 90-day complication rates between RA and nonrobotic-assisted (NRA) lumbar spinal fusions in propensity-matched cohorts. STUDY DESIGN/SETTING Retrospective single center observational propensity-matched observational cohort study. PATIENT SAMPLE Patients who underwent 1- to 3-level lumbar fusion surgery for degenerative conditions. OUTCOME MEASURES Surgical and medical (major/minor) complications at intraoperative, immediately postoperative, 30- and 90-day postoperative intervals. Additionally, reoperations and readmissions within 90 days. METHODS Of 146 RA cases that met inclusion criteria, 114 were successfully propensity matched to 114 patients from 214 cases who had 1-3 level lumbar fusion without robotic assistance based on age, sex, BMI, smoking status, surgical approach (posterior-only or anterior-posterior), ASA grade, revision vs primary, number of surgical levels, and number of interbody levels. We excluded tumor, trauma, infection or deformity cases. Continuous variables were compared using unpaired t-tests and categorical variables were compared using Fisher's exact test with significance set at 0.05. RESULTS Consistent with propensity matching, there was no difference in patient demographics and baseline characteristics between groups. Neither group had intraoperative fixation-related complications or required a return to OR for malpositioned screws. All cause intraoperative complication rates were similar between NRA (5.3%) and RA groups (10.5%, p=0.366). Immediate postoperative medical complication rate was also similar between NRA (6.1%) and RA groups (1.8%, p=0.089). Thirty-day complication rates (NRA:15.8% vs RA:12.3%, p=0.446), 90-day complication rates (NRA:15.8% vs RA:14.9%, p=0.854), reoperation rates (NRA:6.1% vs RA:3.5%, p=0.354), and readmission rates (NRA:7.0% vs RA:6.1%, p=0.789) showed no difference between NRA and RA groups. There was no difference between return to OR for infection between the cohorts (NRA:6 [5%] vs RA:1 [0.8%], p=0.119). There was, however, improved length of stay (LOS) in the RA group compared to NRA group (2.5 vs 3.17 days, p=0.018). CONCLUSIONS In propensity-matched cohorts, patients undergoing 1- to 3-level level RA posterior lumbar fusion for degenerative conditions did not have increased 90-day complication rate, and had a shorter length of stay compared to NRA patients. There findings differ from a prior administrative database study as the RA group in the current study had 0% return to OR for malpositioned screws and 0.8% return to OR for infection. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Computed tomography (CT) measurement of Hounsfield Units (HU) has been described as a tool for assessing bone mineral density (BMD). For surgeons considering a revision lumbar fusion, knowledge of the BMD of the upper instrumented verterbra (UIV) is of value for surgical planning. However, the presence of metal artifact from instrumentation presents a potential confounder and prior studies have not validated measurements of HU in this setting. PURPOSE The purpose of this study is to determine if HU can be measured reliably at instrumented levels after a lumbar fusion. STUDY DESIGN/SETTING Retrospective observational cohort at a single multisurgeon spine center. PATIENT SAMPLE Consecutive series of patients who had lumbar CT Scans after an instrumented posterior lumbar fusion. OUTCOME MEASURES Hounsfield Units at the upper instrumented vertebra and levels proximal. METHODS We analyzed pre- and postoperative CT scans of 50 patients who underwent L2 and distal instrumented lumbar fusion whose scans were no greater than 1 year apart, obtaining HU measurements of analogous axial cuts at the upper instrumented level (immediately caudal to the halo of the pedicle screw), as well as additional control levels above the construct. RESULTS The HU at the pre-and postoperative UIV exhibited a strong correlation (r=0.917, p CONCLUSIONS Postoperative HU at the UIV was strongly correlated with and not significantly different from the preoperative HU. Although the HU in the vertebrae proximal to the UIV were slightly lower postoperatively, this change was predictable using a correction factor. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

OBJECTIVEPatient-reported outcomes (PROs) such as the Oswestry Disability Index (ODI) and EuroQol-5D (EQ-5D) are widely used to evaluate treatment outcomes following spine surgery for degenerative conditions. The goal of this study was to use the Charlson Comorbidity Index (CCMI) as a measure of general health status, for comparison with standard PROs.METHODSThe authors examined serial CCMI scores, complications, and PROs in 371 patients treated surgically for degenerative lumbar spine conditions who were enrolled in the Quality and Outcomes Database from a single center. The cohort included 152 males (41%) with a mean age of 58.7 years. Patients with no, minor, or major complications were compared at baseline and at 1 year postoperatively.RESULTSMinor complications were observed in 177 patients (48%), and major complications in 34 (9%). There were no significant differences in preoperative ODI, EQ-5D, or CCMI among the 3 groups. At 1 year, there was a significantly greater deterioration in CCMI in the major complication group (1.03) compared with the minor (0.66) and no complication groups (0.44, p < 0.006), but no significant difference in ODI or EQ-5D.CONCLUSIONSDespite equivalent improvements in PROs, patients with major complications actually had greater deterioration in their general health status, as evidenced by worse CCMI scores. Because CCMI is predictive of medical and surgical risk, patients who sustained a major complication now carry a greater likelihood of adverse outcomes with future interventions, including subsequent spine surgery. Although PRO scores are a key metric, they fail to adequately reflect the potential long-term impact of major perioperative complications.

OBJECTIVEThe aim of this paper was to use a prospective, longitudinal, multicenter outcome registry of patients undergoing surgery for lumbar degenerative disease in order to assess the incidence and factors associated with 30-day reoperation and 90-day readmission.METHODSProspectively collected data from 9853 patients from the Quality and Outcomes Database (QOD; formerly known as the N2QOD [National Neurosurgery Quality and Outcomes Database]) lumbar spine registry were retrospectively analyzed. Multivariate binomial regression analysis was performed to identify factors associated with 30-day reoperation and 90-day readmission after surgery for lumbar degenerative disease. A subgroup analysis of Medicare patients stratified by age (< 65 and ≥ 65 years old) was also performed. Continuous variables were compared using unpaired t-tests, and proportions were compared using Fisher’s exact test.RESULTSThere was a 2% reoperation rate within 30 days. Multivariate analysis revealed prolonged operative time during the index case as the only independent factor associated with 30-day reoperation. Other factors such as preoperative diagnosis, body mass index (BMI), American Society of Anesthesiologists (ASA) class, diabetes, and use of spinal implants were not associated with reoperations within 30 days. Medicare patients < 65 years had a 30-day reoperation rate of 3.7%, whereas those ≥ 65 years had a 30-day reoperation rate of 2.2% (p = 0.026). Medicare beneficiaries younger than 65 years undergoing reoperation within 30 days were more likely to be women (p = 0.009), have a higher BMI (p = 0.008), and have higher rates of depression (p < 0.0001). The 90-day readmission rate was 6.3%. Multivariate analysis demonstrated that higher ASA class (OR 1.46 per class, 95% CI 1.25–1.70) and history of depression (OR 1.27, 95% CI 1.04–1.54) were factors associated with 90-day readmission. Medicare beneficiaries had a higher rate of 90-day readmissions compared with those who had private insurance (OR 1.43, 95% CI 1.17–1.76). Medicare patients < 65 years of age were more likely to be readmitted within 90 days after their index surgery compared with those ≥ 65 years (10.8% vs 7.7%, p = 0.017). Medicare patients < 65 years of age had a significantly higher BMI (p = 0.001) and higher rates of depression (p < 0.0001).CONCLUSIONSIn this analysis of a large prospective, multicenter registry of patients undergoing lumbar degenerative surgery, multivariate analysis revealed that prolonged operative time was associated with 30-day reoperation. The authors found that factors associated with 90-day readmission included higher ASA class and a history of depression. The 90-day readmission rates were higher for Medicare beneficiaries than for those who had private insurance. Medicare patients < 65 years of age were more likely to undergo reoperation within 30 days and to be readmitted within 90 days after their index surgery.

Retrospective cohort.To determine if the use of cell saver reduces overall blood costs in adult spinal deformity (ASD) surgery.Recent studies have questioned the clinical value of cell saver during spine procedures.ASD patients enrolled in a prospective, multicenter surgical database who had complete preoperative and surgical data were identified. Patients were stratified into (1) cell saver available during surgery, but no intraoperative autologous infusion (No Infusion group), or (2) cell saver available and received autologous infusion (Infusion group).There were 427 patients in the Infusion group and 153 in the No infusion group. Patients in both groups had similar demographics. Mean autologous infusion volume was 698 mL. The Infusion group had a higher percentage of EBL relative to the estimated blood volume (42.2%) than the No Infusion group (19.6%, p.000). Allogeneic transfusion was more common in the Infusion group (255/427, 60%) than the No Infusion group (67/153, 44%, p = .001). The number of allogeneic blood units transfused was also higher in the Infusion group (2.4) than the No Infusion group (1.7, p = .009). Total blood costs ranged from $396 to $2,146 in the No Infusion group and from $1,262 to $5,088 in the Infusion group. If the cost of cell saver blood was transformed into costs of allogeneic blood, total blood costs for the Infusion group would range from $840 to $5,418. Thus, cell saver use yielded a mean cost savings ranging from $330 to $422 (allogeneic blood averted). Linear regression showed that after an EBL of 614 mL, cell saver becomes cost-efficient.Compared to transfusing allogeneic blood, cell saver autologous infusion did not reduce the proportion or the volume of allogeneic transfusion for patients undergoing surgery for adult spinal deformity. The use of cell saver becomes cost-efficient above an EBL of 614 mL, producing a cost savings of $330 to $422.Level III.

OBJECTIVEThe authors conducted a study to compare neurological deficit rates associated with complex adult spinal deformity (ASD) surgery when recorded in retrospective and prospective studies. Retrospective studies may underreport neurological deficits due to selection, detection, and recall biases. Prospective studies are expensive and more difficult to perform, but they likely provide more accurate estimates of new neurological deficit rates.METHODSNew neurological deficits were recorded in a prospective study of complex ASD surgeries (pSR1) with a defined outcomes measure (decrement in American Spinal Injury Association lower-extremity motor score) for neurological deficits. Using identical inclusion criteria and a subset of participating surgeons, a retrospective study was created (rSR1) and neurological deficit rates were collected. Continuous variables were compared with the Student t-test, with correction for multiple comparisons. Neurological deficit rates were compared using the Mantel-Haenszel method for standardized risks. Statistical significance for the primary outcome measure was p < 0.05.RESULTSOverall, 272 patients were enrolled in pSR1 and 207 patients were enrolled in rSR1. Inclusion criteria, defining complex spinal deformities, and exclusion criteria were identical. Sagittal Cobb measurements were higher in pSR1, although sagittal alignment was similar. Preoperative neurological deficit rates were similar in the groups. Three-column osteotomies were more common in pSR1, particularly vertebral column resection. New neurological deficits were more common in pSR1 (pSR1 17.3% [95% CI 12.6–22.2] and rSR1 9.0% [95% CI 5.0–13.0]; p = 0.01). The majority of deficits in both studies were at the nerve root level, and the distribution of level of injury was similar.CONCLUSIONSNew neurological deficit rates were nearly twice as high in the prospective study than the retrospective study with identical inclusion criteria. These findings validate concerns regarding retrospective cohort studies and confirm the need for and value of carefully designed prospective, observational cohort studies in ASD.

Study Design: Case series and literature review. Objective: There is a growing body of literature supporting that osteochondroma of the spine may not be as rare as previously documented. The purpose of this study was to perform an updated review and present our experience with 4 cases of solitary osteochondroma of the spine, including surgical treatment and subsequent outcomes. Methods: A review of 4 cases and an updated literature review. Results: All 4 cases were diagnosed as solitary osteochondroma of the spine based on clinical and histopathologic findings. Majority of the lesions arose from the posterior column with one case showing extension into the middle column with clinical neurologic sequelae. Treatment strategies for all cases included complete marginal excision of the lesions using a posterior approach. All 4 cases showed no radiographic evidence of recurrence. The literature review yielded 132 cases of solitary osteochondroma and 17 case associated with multiple hereditary exostosis. Out of the 132 cases, 36 presented with myelopathic symptoms. Conclusion: Osteochondroma of the spine may not be as rare as previously reported. The best approach to treatment in almost all symptomatic cases include wide surgical excision of the tumor. This should include complete resection of the cartilaginous cap of the tumor in an effort to prevent recurrence. When excision is performed properly, the outcomes are excellent with very low recurrence of the tumor.

Advancements in the understanding of adult spinal deformity have led to a greater awareness of the role of the pelvis in maintaining sagittal balance and alignment. Pelvic incidence has emerged as a key radiographic measure and should closely match lumbar lordosis. As proper measurement of the pelvic incidence requires accurate identification of the S-1 endplate, lumbosacral transitional anatomy may lead to errors. The purpose of this study is to demonstrate how lumbosacral transitional anatomy may lead to errors in the measurement of pelvic parameters. The current case highlights one of the potential complications that can be avoided with awareness. The authors report the case of a 61-year-old man who had undergone prior lumbar surgeries and then presented with symptomatic lumbar stenosis and sagittal malalignment. Radiographs showed a lumbarized S-1. Prior numbering of the segments in previous surgical and radiology reports led to a pelvic incidence calculation of 61°. Corrected numbering of the segments using the lumbarized S-1 endplate led to a pelvic incidence calculation of 48°. Without recognition of the lumbosacral anatomy, overcorrection of the lumbar lordosis might have led to negative sagittal balance and the propensity to develop proximal junction failure. This case illustrates that improper identification of lumbosacral transitional anatomy may lead to errors that could affect clinical outcome. Awareness of this potential error may help improve patient outcomes.

BACKGROUND CONTEXT Lumbar spinal stenosis (LSS) is a common condition in the elderly population and is associated with significant morbidity and decreased quality of life. Many patients manage with little to no treatment, but for the patients in whom lower extremity pain and disability are unacceptable, surgical intervention is shown to provide good relief of symptoms and pain. There is little evidence on how many patients obtain a clinically relevant improvement in function and whether this effect is sustained 5 years after surgery. PURPOSE The aim of this study was to evaluate the proportion of patients who achieve and maintain a clinically relevant improvement at 1, 2 and 5 years postoperatively. STUDY DESIGN/SETTING The study was performed as a retrospective cohort study on patients who underwent surgery at the Spine Centre of Southern Denmark, Middelfart; The Regional Hospital of Silkeborg and University Hospital of Zealand in Koge. PATIENT SAMPLE A total of 6,063 patients who underwent decompression due to spinal stenosis at three spine centers in Denmark were included in our study. We had follow-up data available on our main outcome measure (ODI) on 75% at 1-year, 70% at 2-year, and 62% at 5-year follow-up. OUTCOME MEASURES Oswestry Disability Index (ODI), EuroQoL-5D-3L (EQ-5D), visual analogue scale leg pain (VAS-leg) and visual analogue scale back pain (VAS-back). METHODS We included patients who underwent first-time decompression due to LSS at three tertiary Spine Centers in Denmark. Data was collected prospectively in the National Spine Registry of Denmark (DaneSpine). Based on the outcome measures, the patients who obtained a minimal clinically relevant difference in outcome (MCID) were identified at 1-, 2- and 5-years post-surgery. RESULTS The mean change from baseline to 5-years post-surgery was 0.2 on EQ-5D; -18.9 on ODI, -18.9 on VAS back and 29.8 on VAS. We found that 86% of patients obtained the MCID on at least one parameter, with 68.9% obtaining MCID on two or more outcome measures. VAS back was found with a statistically important difference in the percentage of patients who achieved MCID at 1- and 5-years postsurgery. For the remaining outcome measures no statistically important difference was found. CONCLUSIONS Decompression as treatment for LSS is a safe and reliable option with low complication rates. Most patients achieve a clinically relevant difference in outcome on one or more parameters, which is maintained 5 years after surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Previous studies have failed to show a clinically significant association between Modic changes (MCs) and patient-reported outcomes (PROs) after discectomy. PURPOSE To assess whether Modic changes (MCs) are associated with health-related quality of life, long-term physical disability, back or leg pain after discectomy. STUDY DESIGN/SETTING A registry-based comparative cohort study with two-year follow-up. PATIENT SAMPLE n=620. OUTCOME MEASURES PROs including ODI, EQ-5D, VAS back and leg pain and patient satisfaction were collected. METHODS Data from the Danish National Spine Registry on patients undergoing first-time lumbar discectomy at a single institution from 2014-17 with an accessible preoperative lumbar MRI, complete preoperative and two-year follow-up questionnaires were obtained. Patients were stratified based on the presence (+MC) or absence (-MC) of MCs on the preoperative MRI. RESULTS Of 620 patients included, MCs were present in 270 patients (47%). Of these, MC type 1 (MC-1) was present in 70 (25%) and MC type 2 (MC-2) in 210 (75%) patients. Preoperative data for ODI, EQ-5D, VAS-BP, and VAS-LP were comparable for the +MC and -MC groups. Both groups had a statistically significant improvement in PRO's from baseline compared to two-year follow-up (p CONCLUSIONS MCs were not found to be associated with health-related quality of life, disability, back- or leg pain or patient satisfaction two years after discectomy. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Patients with lumbar spinal stenosis present with low back pain, numbness and pain in the legs and gait difficulties due to neurogenic claudication. Patients often walk in a stooped posture to increase the spinal canal diameter by stretching out the ligamentum flavum. This stooped posture leads to a positive sagittal balance. After decompressive surgery, patients may walk in a less stooped manner, improving their sagittal balance, which may lead to less back pain and improved patient reported outcomes. PURPOSE To determine if sagittal balance will improve in patients with spinal stenosis after decompression alone. STUDY DESIGN/SETTING Prospective longitudinal cohort study. PATIENT SAMPLE Patients with lumbar spinal stenosis who underwent decompression alone. OUTCOME MEASURES Oswestry Disability Index (ODI), visual analogue scale (VAS)- leg and back pain. METHODS This study compares preoperative and 6-month postoperative full-length 36” standing lateral and posterior-anterior x-rays and 1-year Oswestry Disability Index (ODI), visual analogue scale (VAS)- leg and back pain, in patients undergoing decompression alone without fusion for central or combined central and lateral stenosis, in patients 60 years and older from March 2016 until September 2017. The following radiographic parameters were measured coronal cobb angle (COBB), pelvic incidence (PI), sagittal vertical axis (SVA), lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence-lumbar lordosis ratio (PI-LL) and sacral slope (SS). RESULTS Forty-five patients (24 males and 21 females) were included. Patients had symptoms for more than 3 months at the time of surgery. Most patients were operated with a bilateral laminectomy over two levels. Sagittal balance showed a statistically significant change in SVA from 65.0mm to 48.6mm (p=0.009) and PI-LL mismatch 7.80 to 4.24 (p= 0.005). A small to moderate association was found between SVA and ODI both preoperatively (r=0.54, p= 0.001) and postoperatively (r=0.51, p= 0.001) and preoperative VAS-leg/back pain (r=0.60, p=0.001)/(r=0.42,p=0.009). CONCLUSIONS There is a statistically significant improvement in sagittal balance in patients undergoing decompression alone for lumbar spinal stenosis. Associations between the SVA and ODI and VAS-leg/back pain indicate that improvements in sagittal balance contribute to improvements in patient reported outcomes. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT The choice of surgical approach in CD surgery is often dictated by surgeon preference and experience. This choice could significantly impact the costs and outcomes of an operation, therefore the approaches should be analyzed in order to determine the optimal approach from a cost-utility perspective. The cost utility of different surgical approaches in cervical deformity (CD) has not been investigated in the literature. PURPOSE Investigate the cost utility of differing approaches in operative CD patients. STUDY DESIGN/SETTING Retrospective review of a prospective multicenter cervical deformity database. PATIENT SAMPLE A total of 105 CD patients. OUTCOME MEASURES Costs, EuroQol-5D (EQ-5D), Quality adjusted life years (QALYs), Cost per quality adjusted life years. METHODS Included CD patients (C2-C7 Cobb>10°or CK>10°, cSVA>4cm or CBVA>25°) >18yr with follow-up (1-year) surgical and health related quality of life scores. Costs were calculated using the PearlDiver database, which reflects both private insurance and Medicare reimbursement claims. QALYs and cost per QALY were calculated using a 3% discount rate to account for residual decline to life expectancy (78.7 years). After accounting for complications, LOS, revisions, and death, cost per QALY at 1Y and life expectancy [LE] were calculated for surgical approach (anterior-only, posterior-only [excluding PSO and VCR to account for differences in instrumentation], combined). In a subanalysis, approach groups were propensity-score matched for TS-CL to account for baseline (BL) deformity. RESULTS A total of 105 CD patients met inclusion criteria (61.9 yrs, 63% female, 28.6kg/m2, CCI: 0.97). By approach, 21.9% underwent anterior only, 37.1% posterior only and 41% combined approaches. Average number of levels fused was 6.9, with a mean EBL of 948 ml and total operative time of 544.2 minutes. Mean EQ5D at BL was 0.74±0.07 and at 1Y was 0.79±0.08 (a difference of 0.05±0.08). Average difference in EQ5D from BL to 1Y was significant (p=0.002) across approach: 0.093 anterior-only, 0.021 posterior-only, 0.044 combined. 13% (3) of anterior-only patients underwent a revision, 10.3% (4) of posterior and 13.9% (6) of combined approaches. The average costs per surgery for CD patients at 1-year undergoing surgery by anterior approach was $27,640.75, $38,499.44 posterior-only, and $36,553.41 combined approach (p>0.05).The cost per QALY was higher for posterior-only patients at 1-year ($948,946.81) compared to anterior-only ($152,616.65) and combined ($424,110.14), p CONCLUSIONS After accounting for comorbidities, complications, revisions, and death, all surgical approaches showed improvement in postoperative EQ5D scores, however posterior approach demonstrated overall lower cost effectiveness. CD patients who underwent anterior-only approach had the lowest average costs for CD corrective surgery, as well as the lowest cost per QALY (best cost-effectiveness) compared to posterior and combined approaches. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Although short-term adult symptomatic lumbar scoliosis (ASLS) outcomes studies favor operative over nonoperative treatment, long-term outcomes are critical for assessment of treatment durability. PURPOSE To assess whether operative treatment for ASLS provides greater improvement of patient-reported outcomes measures than nonoperative treatment at 5-6-year follow-up. STUDY DESIGN/SETTING Secondary analysis of prospective multicenter cohort. PATIENT SAMPLE Adults with symptomatic lumbar scoliosis enrolled into an NIH-sponsored study to assess outcomes of operative and nonoperative treatments. OUTCOME MEASURES Scoliosis Research Society-22 subscore (SRS-22 subscore), Oswestry Disability Index (ODI), occurrence of related serious adverse events (SAEs) METHODS The ASLS study is an NIH-sponsored multicenter prospective study to assess operative vs nonoperative treatment for ASLS, with randomized and observational treatment arms. Patients were 40-80 years of age with ASLS (Cobb >30° and ODI >20 or SRS-22 subscore (SRS-22) RESULTS The 286 ASLS patients (108 nonoperative, 178 operative) had follow-up rates at 2 and 5-6 years of 90% (256) and 74% (212), respectively. At 5 years, compared with nonoperative, operative patients had greater improvement in SRS-22 subscore (adjusted mean difference, 0.6 [95% CI, 0.5 to 0.6]) and ODI (adjusted mean difference, -14 [95% CI, -18 to -9]) (p CONCLUSIONS The significantly greater clinical improvement of operative vs nonoperative treatment for ASLS at 2 years is maintained at 5-6-year follow-up. Overall, operative patients with a related SAE still had greater improvement than nonoperative patients, but for operative patients with 2+ SAEs, the TEs were markedly reduced. These findings have important implications for patient counseling and cost-effectiveness assessments. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Due to poor bone stock in the elderly, with concerns of screw pull-out, a non-instrumented fusion is commonly performed in Scandinavia when lumbar instability is present. Allograft bone is often used as graft extender with consequent low fusion rates. In an attempt to increase fusion rates, we conducted an RCT comparing ABM/P-15 versus allograft in non-instrumented lumbar fusion surgery. Despite obtaining an overall fusion rate of 59% in the ABM/P-15 group compared to 35% in the allograft graft group based on 1-year postoperative fine cut CT-scans, Patient Reported Outcomes (PROs) at 2 years post operatively were similar between the two groups. PURPOSE To compare 5-year PROs of patients with non-instrumented posterolateral fusion due to degenerative spondylolisthesis with either 15 amino acid residue (ABM/P-15) or allograft. STUDY DESIGN/SETTING Randomized clinical trial. PATIENT SAMPLE Patients 65 years or older with spinal stenosis and degenerative spondylolisthesis (DS) who previously underwent decompression and non-instrumented posterolateral fusion a minimum 5 years prior. OUTCOME MEASURES Oswestry Disability Index (ODI), Visual analog scales (VAS) for Back (BP) and Leg Pain (LP) and EuroQOL-5D (EQ5D). METHODS A total of 101 patients were enrolled in the study and randomized 1:1 to either ABM/P-15 (mixed 50/50, 5cc/level) or allograft bone (30g/level), both mixed with local bone graft. PROs were collected at baseline and at 12, 24 and 60 months postoperative. RESULTS The two groups were similar in terms of sex distribution, age and number of levels fused at baseline. There were 98 patients available for analysis after 1 year, 90 and 78 patients after 2 and 5 years. Patients in both groups reported clinically and statistically significant improvements in all PROs from baseline to postoperative on all outcome measures. At 5 years follow-up, no significant differences were reported on LP (ABM/P-15=25,8 vs 32,0, p=0,36) or EQ5D (ABM/P-15=0,81 vs 0,74, p=0,21) whereas ODI (ABM/P-15=18,6 vs 27,0, p= 0,04) and BP (ABM/P-15=22,5 vs 38,4, p=0,02) were statistically significant better in the ABM/P-15 group. CONCLUSIONS At the 5-year follow-up period, patients who had non-instrumented posterolateral fusion augmented with ABM/P-15 had better ODI and BP scores compared to the allograft only group, despite showing similar PROs at the 2-year follow-up period. FDA DEVICE/DRUG STATUS ABM/P-15 (Investigational/Not approved)

BACKGROUND CONTEXT Medical comorbidities, particularly anxiety or depression, may potentially influence how patients perceive clinical benefit after surgery. The current study defined and compared minimum clinically important difference (MCID) thresholds in patients with and without anxiety/depression and obesity undergoing fusion for grade 1 degenerative spondylolisthesis. PURPOSE To determine if preoperative psychiatric diagnoses, more than obesity, alters the MCID threshold in patients undergoing fusion for spondylolisthesis. STUDY DESIGN/SETTING Retrospective analysis of multicenter, prospective database. PATIENT SAMPLE Patients who underwent lumbar fusion for grade 1 degenerative spondylolisthesis from January 2014 to August 2017 enrolled in the Quality Outcomes Database (QOD). OUTCOME MEASURES Oswestry Disability Index (ODI), EuroQOL5D (EQ-5D), back (BP, 0-10) and leg pain (LP, 0-10) scores METHODS The QOD was queried for patients who underwent lumbar fusion for grade 1 degenerative spondylolisthesis from January 2014 to August 2017. Patient Reported Outcomes (PROs) included ODI, EQ-5D, BPand LP scores. Both anchor-based and distribution-based methods for MCID calculation were used. RESULTS Of 462 eligible cases, 356 (77%) had complete baseline and 12-month PROs. The MCID values for ODI were similar in patients with and without a diagnosis of obesity (20.58 and 20.69, respectively), and with and without anxiety/depression (24.72 and 22.56, respectively). The MCID values for BP, LP, and EQ-5D were also similar among all groups regardless of method used to determine MCID. CONCLUSIONS MCID thresholds for ODI, EQ5D, back pain and leg pain in patients with and without anxiety/depression and obesity undergoing spinal fusion for grade 1 degenerative spondylolisthesis are similar. Preoperative clinical and shared decision-making may be improved by understanding that preop medical comorbidities do not affect how patients determine an important clinical change postoperatively. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Background Shared decision making (SDM) is a systematic approach aimed at improving patient involvement in preference-sensitive health care decisions. Choosing between surgical or non-surgical treatment for lumbar disc herniation, can be difficult as the evidence of a superior treatment is unclear, which makes it a preference-sensitive decision. The objectives of this study was therefore to assess the degree of SDM and afterwards to develop and test a patient decision aid (PtDA) to support SDM during the clinical encounter between surgeon and patient, when patients choose between surgical and non-surgical treatment for Lumbar disc herniation (LDH). Methods The study was conducted in four steps. Assessment of the extent to which SDM was practiced in the spine clinic. Development of a PtDA to support SDM. Testing its usability and acceptability amongst potential users (patients). Pilot-test of its usability in the clinical setting. Results Results from our small baseline study (n = 40) showed that between a third and two-thirds of the patients reported not being fully engaged in a shared decision. A pre-designed template (BESLUTNINGSHJÆLPER™) was adapted to support the decision about whether or not to have surgery for LDH. Testing the prototype with patients led to minor refinements. A subsequent pilot test of its usability in a clinical setting achieved positive responses from both patients and clinicians. Conclusion Our baseline study demonstrated that SDM was not universally practiced in the clinic. The PtDA we have developed was rated as acceptable and usable by both patients and clinicians for helping those with LDH choose between surgical or non- surgical treatment. This tool now requires further testing to assess its effectiveness.

Study Design:Systematic review and case series.Objectives:Any acute injury to the posterior elements of the lumbar spine resulting in listhesis is considered a traumatic spondylolisthesis. This rare injury caused by high-energy trauma is variably described in the literature as fracture-dislocation, where only case reports and series have been published. Our objectives were to propose evidence-based treatment recommendations and a new classification system for this injury.Methods:A systematic review of literature from PubMed, EMBASE, and Cochrane without time frame limitations was performed, which included 77 level IV and V articles and 9 patients as case series in the analysis.Results:A total of 125 cases were reviewed with mean age of 30.5 years. Half of the cases resulted from a vehicular accident. Back pain presented in 82%, while 50% had neurologic deficits. Operative treatment was performed in 93.6% (posterior decompression [PD] = 4%; posterior spinal fusion [PSF] = 43.2%; interbody fusion [IB] = 46.4%) with overall fusion rates of 74%. Binomial regression analysis for achieving solid fusion showed a 28.6× higher odds for IB compared to PSF ( P = .008, r2= 0.633). Subanalysis of cases with disc injuries revealed higher fusion outcomes for IB (87%) compared to PSF (46%; P = .006), while there were no significant differences for patients without disc injury. Pain and neurological symptoms improved significantly on final follow-up ( P < .001). Overall complication rate was 22%.Conclusion:Operative management with reduction, decompression for neurologic deficits, instrumentation, and fusion is recommended for traumatic spondylolisthesis. Interbody fusion is recommended to achieve better fusion outcomes especially with preoperatively identified disc lesions.

A survey was administered to a random sampling of the American Academy of Orthopaedic Surgeons (AAOS) members to determine the rate at which recently trained orthopedic surgeons switch their first job and to identify factors affecting the job selection process. There were 351 (21%) respondents. Respondents considered practice location (41%), practice type (28%), and family proximity (23%) as most important while research opportunity (54%) and signing bonus (33%) were considered least important in their first job. Half of the respondents (51%) left their first job before the completion of their fifth year; most left for financial reasons (34%) or because the practice was not as advertised (31%). Many (53%) stated they had minimal training in selecting their first job and most (88%) felt inadequately prepared for the business side of orthopedics. Further studies are needed to evaluate the high rate of initial post-training job attrition to decrease the personal and societal costs of this phenomenon.