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Anemia is a modifiable risk factor for postoperative complications following surgery. This study aimed to determine the impact of preoperative anemia severity on 30-day postoperative complications following adult spinal deformity (ASD) surgery.Adults undergoing spinal fusion for ASD from 2012 to 2018 were identified in the National Surgical Quality Improvement Program database. Patients were substratified into 3 cohorts-non-anemia, mild anemia, and moderate-to-severe anemia-based on World Health Organization definitions. We assessed 30-day wound, cardiac, pulmonary, renal, and thromboembolic complications, as well as sepsis, mortality, postoperative transfusions, extended length of stay, and reoperation. Bivariate analyses and multivariable logistic regression were performed.Of 2173 patients, 1694 (78%) had no anemia, 307 (14%) had mild anemia, and 172 (8%) had moderate or severe anemia. Following adjustments, patients with mild anemia were more likely to have postoperative blood transfusions (odds ratio [OR] 1.80, P 0.001) and extended length of stay (OR 1.43, P 0.001). Patients with moderate-to-severe anemia were at increased risk of organ space infection (OR 3.27, P = 0.028), death (OR 13.15, P = 0.001), postoperative blood transfusion (OR 2.81, P 0.001), and extended length of stay (OR 3.02, P 0.001).We found a stepwise and approximately two-fold increase in the odds ratio of postoperative transfusion and length of stay with increasing severity of anemia. Moderate-to-severe anemia was associated with increased odds of death and organ space infection. Patients with moderate-to-severe anemia should be medically optimized before ASD surgery.

Tibial tuberosity fracture (TTF) is an uncommon injury occurring mostly in adolescents. The association between race and TTF has not been investigated. We aimed to determine whether there is an association between race and hospital admission for pediatric TTF and to evaluate previously determined risk factors for TTF using a large sample.This was a cross-sectional analysis of the Agency for Healthcare Research and Quality/Healthcare Cost and Utilization Project 2016 Kids' Inpatient Database (KID). We compared admissions for TTF to admissions for all other diagnoses. Because forearm fracture has not been found to be associated with race, univariate and multivariate analyses comparing admissions for TTF to admissions for forearm fracture were also performed. Sample weights were used to preserve national estimates.Of 692 patients admitted for TTF in 2016, 93.2% were male. Factors associated with TTF admission compared with other admission diagnoses on multivariate analysis included male sex (adjusted odds ratio (aOR) 17.67, confidence interval (CI) 12.25-25.47), age 13 to15 (aOR 10.33, CI 5.67-18.82, reference: age 8-12), and black (aOR 8.04, CI 3.91-16.49) and Hispanic (aOR 2.69, 95% CI 1.30-5.55) races/ethnicities (reference: Caucasian). Compared with forearm fracture admission, black race had an aOR of 22.05 (CI 10.08-48.21) for TTF admission on multivariate analysis. The effect of race on TTF admission also varied significantly with age, with 12 years carrying the strongest association of black race with TTF admission.Black race is a previously unreported, strong independent risk factor for TTF. Male sex and age 13 to 15 are also strong risk factors for TTF, making this a highly selective fracture.Prognostic Level III.

There is limited research on the supply and distribution of orthopaedic surgeons in the United States. The goal of this study was to analyze the association of orthopaedic surgeon distribution in the United States with geographic and sociodemographic factors.County-level data from the US Department of Health and Human Services Area Health Resources Files were used to determine the density of orthopaedic surgeons across the United States on a county level. Data were examined from 2000 to 2019 to analyze trends over time. Bivariate and multivariable negative binomial regression models were constructed to identify county-level sociodemographic factors associated with orthopaedic surgeon density.In 2019, 51% of the counties in the United States did not have an orthopaedic surgeon. Metropolitan counties had a mean of 22 orthopaedic surgeons per 100,000 persons while nonmetropolitan and rural counties had a mean of 2 and 0.1 orthopaedic surgeons per 100,000 persons, respectively. Over the past 2 decades, there was a significant increase in the percentage of orthopaedic surgeons in metropolitan counties (77% in 2000 vs 93% in 2019, P0.001) and in the proportion of orthopaedic surgeons 55 years and older (32% in 2000 vs 39% in 2019, P0.001). Orthopaedic surgeon density increased with increasing median home value (P0.001) and median household income (P0.001). Counties with a higher percentage of persons in poverty (P0.001) and higher unemployment rate (P0.001) and nonmetropolitan (P0.001) and rural (P0.001) counties had a lower density of orthopaedic surgeons. On multivariable analysis, a model consisting of median home value (P0.001), rural counties (P0.001), percentage of noninsured persons (P0.001), and percentage of foreign-born persons (P0.001) predicted orthopaedic surgeon density.Access to orthopaedic surgeons in the United States in rural areas is decreasing over time. County-level socioeconomic factors such as wealth and urbanization were found to be closely related with surgeon density.

Selection of appropriate candidates for simultaneous bilateral total knee arthroplasty (si-BTKA) is crucial for minimizing postoperative complications. The aim of this study was to develop a scoring system for identifying patients who may be appropriate for si-BTKA. Patients who underwent si-BTKA were identified in the National Surgical Quality Improvement Program database. Patients who experienced a major 30-day complication were identified as high-risk patients for si-BTKA who potentially would have benefitted from staged bilateral total knee arthroplasty. Major complications included deep wound infection, pneumonia, renal insufficiency or failure, cerebrovascular accident, cardiac arrest, myocardial infarction, pulmonary embolism, sepsis, or death. The predictive model was trained using randomly split 70% of the dataset and validated on the remaining 30%. The scoring system was compared against the American Society of Anesthesiologists (ASA) score, the Charlson Comorbidity Index (CCI), and legacy risk-stratification measures, using area under the curve (AUC) statistic. Total 4,630 patients undergoing si-BTKA were included in our cohort. In our model, patients are assigned points based on the following risk factors: +1 for age ≥ 75, +2 for age ≥ 82, +1 for body mass index (BMI) ≥ 34, +2 for BMI ≥ 42, +1 for hypertension requiring medication, +1 for pulmonary disease (chronic obstructive pulmonary disease or dyspnea), and +3 for end-stage renal disease. The scoring system exhibited an AUC of 0.816, which was significantly higher than the AUC of ASA (0.545; p

Myocardial infarction (MI), and its predictive factors, has been an understudied complication following spine operations. The objective was to assess the risk factors for perioperative MI in elective spine surgery patients as a retrospective case control study. Elective spine surgery patients with a perioperative MI were isolated in the NSQIP. The relationship between MI and non-MI spine patients was assessed using chi-squared and independent samples t-tests. Univariate/multivariate analyses assessed predictive factors of MI. Logistic regression with stepwise model selection was employed to create a model to predict MI occurrence. The study included 196,523 elective spine surgery patients (57.1 yrs, 48%F, 30.4 kg/m

Study design Retrospective. Objective The purpose of this study was to assess trends in utilization rates of adult spinal deformity (ASD) surgery, as well as perioperative surgical metrics between black and white patients undergoing operative treatment for ASD in the United States. Summary of background data Racial disparities in access to care, complications, and surgical selection have been shown to exist in the field of spine surgery. However, there is a paucity of data concerning racial disparities in the management of ASD patients. Methods Adult patients undergoing ASD surgery from 2004 to 2014 were identified in the Nationwide Inpatient Sample (NIS). Utilization rates, major complications rates, and length of stay (LOS) for black patients and white patients were trended over time. Utilization rates were reported per 1,000,000 people and determined using annual census data among subpopulations stratified by race. All reported complication rates and prolonged hospital stay rates are adjusted for Elixhauser Comorbidity Index, income quartile by zip code, and insurance payer status. Results From 2004 to 2014, ASD utilization for black patients increased from 24.0 to 50.9 per 1,000,000 people, whereas ASD utilization for white patients increased from 29.9 to 73.1 per 1,000,000 people, indicating a significant increase in racial disparities in ASD utilization (p-trend 0.05 for both). Conclusion Although black and white patients undergoing ASD surgery do not differ significantly in terms of postoperative complications and length of hospital stay, there is a growing disparity in utilization of ASD surgery between white and black patients from 2004 to 2014 in the United States. There is need for continued focus on identifying ways to reduce racial disparities in surgical selection and perioperative management in spine deformity surgery.Level of Evidence: 3.

BACKGROUND CONTEXT The relationship between biopsychosocial factors (the interaction of biologic factors, behavioral factors, and social factors that affect overall health) and quality of life is well established in spine surgery patients. Sleep hygiene is an important component of wellbeing and is closely linked to mental health. Despite the importance of sleep hygiene and the strong association between poor sleep and mental health disorders, little is known about how sleep disturbance (SD) in patients with spine conditions correlates with validated health-related quality-of-life (HRQOL) measures or the degree to which SD changes after surgery. PURPOSE Our objectives were to determine the (1) prevalence of SD among patients presenting for spine surgery at a large academic medical center; (2) correlation between SD and HRQOL scores; and (3) association between postoperative SD resolution and short-term HRQOL. We hypothesized that SD would be significantly correlated with HRQOL in patients undergoing elective spine surgery. In addition, we hypothesized that postoperative resolution of SD would be significantly associated with improved HRQOL. STUDY DESIGN/SETTING The current study is a retrospective review of these prospectively collected data from patients who presented for spine surgery at an academic medical center. PATIENT SAMPLE Eligible patients were English-speaking, were aged 18 years or older, had undergone elective surgery for degenerative lumbar or cervical spine disease or for correction of spinal deformity, and had completed preoperative and immediate postoperative assessments. Of 1,193 patients enrolled, we included the 508 (43%) who met our inclusion criteria. Of these, 226 (44%) had complete 1-year follow-up. Participants’ mean age was 60 years (standard deviation, 13 years), and most were non-Hispanic (98%), and White (73%). All participants were treated at the same center by 5 fellowship-trained, board-certified spine surgeons with 6–26 years in practice. We found no significant differences in age (P = 0.98), sex (P = 0.73), or prevalence of SD (P = 0.17) between included and excluded patients. OUTCOME MEASURES Participants completed an assessment before surgery of sociodemographic and clinical information. Sociodemographic information comprised age, sex, race/ethnicity, highest educational attainment, annual household income, and relationship status. Highest educational attainment was categorized as less than 4-year college degree; 4-year college degree; or post-graduate degree. Annual household income was categorized as $80,000. Relationship status was used to determine whether a participant lived alone or with a partner. Clinical information was presence of comorbid conditions, current use of opioid medication, and presence of intraoperative and/or postoperative complications. Participants completed assessments of their health and wellness before and after surgery. After surgery, assessments were completed during the immediate postoperative period (6–12 weeks) and at 6, 12, and 24 months. These assessments were the Oswestry Disability Index (ODI) or the Neck Disability Index (NDI) and the Patient-Reported Outcome Measurement Information System (PROMIS-29) health domains. METHODS Using preoperative PROMIS SD scores, we grouped participants as having no sleep disturbance (score RESULTS Preoperative SD was reported by 127 participants (25%). SD was significantly correlated with worse ODI/NDI values and worse scores in all PROMIS health domains (all, P CONCLUSIONS One-quarter of spine surgery patients reported preoperative SD of at least moderate severity. Poor preoperative sleep quality and ongoing postoperative sleep disturbance were significantly associated with worse scores on several HRQOL measures. These results highlight the importance of addressing patients’ sleep disturbance both before and after surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Posterior vertebral column resection (pVCR) is a powerful tool for correcting rigid spinal deformity; however, it is a technically demanding procedure and may be associated with a substantial rate of complications(1). pVCR is often reserved for appropriately selected patients with severe focal deformity, in whom soft-tissue releases and posterior column osteotomies alone are unlikely to achieve satisfactory correction. Surgeon experience has also been shown to be correlated with outcomes(2), placing further emphasis on appropriate training and practice before performing pVCR. DESCRIPTION: All surgeries are performed with the patient in the prone position under continuous neuromonitoring. The posterior approach to the spine and spinal instrumentation are performed in a standard fashion(3). The S2-alar-iliac technique is utilized for sacropelvic fixation when indicated(4). A minimum of 6 fixation points above and 6 below the level of resection are obtained, resulting in 2 instrumented blocs proximally and distally. A wide decompressive laminectomy with foraminotomies is then performed at the resection level, allowing for visualization of the spinal cord and exiting nerve roots. In the thoracic spine, disarticulating 3 to 4 cm of the medial rib at the resection level allows for better visualization and accessibility. Temporary fixation is then obtained by a unilateral rod spanning the osteotomy site. Focus is then directed toward the inferior and superior articular facets and pedicle, which are resected in a piecemeal manner from lateral to medial. Care must be taken to avoid damaging nearby nerve roots, especially at the inferomedial aspect of the pedicle. Cancellous bone removal from the vertebral body is then performed in a piecemeal manner through a lateral extra-cavitary approach from each side. This step necessitates transferring temporary fixation to the contralateral side in order to ensure adequate resection bilaterally. Posterior cortex is then resected. The anterior dura is carefully freed of any ligament or bone. Resection of the discs above and below the resection level is then performed, and the end plates are prepared for arthrodesis. The next step is to measure the defect. The sizing of the cages must be kept in line with the desired degree of correction, preventing overlengthening of the spinal column and subsequent stretching of the spinal cord. An en-bloc reduction-fixation across the osteotomy site is performed with use of intercalary connecting rods in order to achieve the desired correction. In situ benders at this stage may be utilized to manipulate the intercalary rods in order to widen the resection space anteriorly. The rods will subsequently be replaced. This technique minimizes stress on the junctional segments through load distribution across the various fixation points in the proximal and distal blocs. Finally, after decortication of the posterior elements, the bone graft is placed prior to layered closure in the standard manner. ALTERNATIVES: Alternative treatments to the pVCR include a standard pedicle-subtraction osteotomy. RATIONALE: A standard pedicle-subtraction osteotomy offers a substantial amount of correction; however, correction is limited to the sagittal plane because the wedge osteotomy is hinged on the anterior cortex. This limitation makes the pVCR a better candidate for patients with severe biplanar deformities. EXPECTED OUTCOMES: pVCR is a complicated and technically challenging procedure that offers substantial correction in the coronal and sagittal planes for patients with rigid spinal deformities. It has also been shown to significantly improve patient quality of life(5) Complication rates, however, are reportedly as high as 25% among older patients with poor physiologic reserve, with postoperative risks including medical complications, neurological deficiencies, surgery-related complications and others(6). Previous studies have demonstrated improved outcomes with increasing surgeon experience(2). IMPORTANT TIPS: Medial rib resection in the thoracic spine allows easy access to the lateral vertebral column. En-bloc fixation-reduction minimizes fixation failure above and below the level of resection and provides a rigid foundation during the correction maneuver. Ensure that the anterior column is disconnected all the way across in order to avoid excessive shortening of the spinal cord and the potential neurologic sequelae. Complete resection of the posterior cortex and scar tissue anterior to the dural sac is required prior to the correction maneuver. Ensure an adequate number of fixation points above and below the resection level.

Hypoalbuminemia is associated with early morbidity and mortality in revision total knee arthroplasty. We evaluated the effect of preoperative hypoalbuminemia on 30-day morbidity and mortality in revision total hip arthroplasty (THA). The National Surgical Quality Improvement Program (NSQIP) database was queried from 2015 to 2018 to identify patients who underwent revision THA. Patients were stratified based on the presence or absence of preoperative hypoalbuminemia and their odds of a major complication or death within 30 days of revision THA with multivariate logistic regression. After Bonferroni correction for these 2 primary outcomes, statistical significance was defined as P P P P P =.020). Hypoalbuminemia is associated with early morbidity and mortality after revision THA. [ Orthopedics . 2022;45(5):281–286.]

Introduction: Relative value units (RVUs) are integral to the U.S. physician compensation system used by the Centers for Medicare & Medicaid Services. The use of 'work RVUs' (herein, wRVUs) is intended to reimburse physicians according to the amount of expertise and effort needed to safely and effectively perform a procedure. Our purpose was to determine: 1) the number of wRVUs/hour generated by common sports medicine surgical procedures; and 2) how patient characteristics, surgical approach, and practice setting are associated with the number of wRVUs/hour. This analysis was performed to infer whether wRVUs are assigned appropriately according to the factors on which they are purported to be based.Methods: We queried the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database for common sports medicine surgical procedures performed in 2018. Data from 19,877 patients (8,258 women) with a mean age of 48 years (range, 18-90) who underwent a surgical sports medicine procedure were analyzed. Work RVUs and operative time were used to calculate work RVUs/hour for each surgical procedure. Univariate and multivariate analyses were used to assess correlations between patient characteristics and wRVUs/hour.Results: Knee chondroplasty generated the most mean (± standard deviation) wRVUs/hour at 22 ± 0.5, whereas 'open tenodesis of biceps tendon, long head' generated the least at 9.6 ± 0.25 wRVUs/hour. Factors associated with a greater mean number of wRVUs/hour were younger patient age, female sex, arthroscopic approach, and outpatient setting. Arthroscopic procedures also generated more wRVUs/hour than the same procedures performed through an open approach. wRVUs were not correlated with case complexity or surgical time.Conclusion: wRVUs/hour in surgical sports medicine procedures vary widely depending on the procedure type, patient characteristics, surgical approach, and practice setting.

Retrospective cohort. To compare postoperative functional improvement in patients who underwent staged versus non-staged anterior–posterior spinal arthrodesis for adult spinal deformity (ASD). In patients with ASD, spinal arthrodesis can be performed in 2 stages to avoid the physiologic insult of a lengthy surgery. The association between staged surgery and postoperative functional improvement has not been well studied. We included 87 patients (59 women) with ASD who underwent anterior–posterior spinal arthrodesis of > 5 levels with fixation to the pelvis from 2010–2014. Primary outcomes were the frequency of achieving at least a minimal clinically important difference (MCID) in the Scoliosis Research Society-22r (SRS-22r) Activity domain and the timeframe in which it was achieved. The secondary outcome was patient satisfaction (SRS-22r Patient Satisfaction domain). A Cox proportional hazard model was used to compare functional improvement over time between staged and non-staged groups. Our study was powered to detect a relative hazard ratio of 0.53, β = 0.20. α = 0.05. The frequency of achieving an MCID in SRS-22r Activity score did not differ significantly between the staged group (33/41 patients) and the non-staged group (34/46 patients) (hazard ratio 0.74; 95% confidence interval 0.41–1.36). Median times to achieving an MCID in SRS-22r Activity score were 191 days (interquartile range: 86–674) in the staged group and 181 days (interquartile range: 72–474) in the non-staged group (p = .75). The staged and non-staged groups had similar SRS-22r Patient Satisfaction scores at 3–9 months postoperatively and at final follow-up (both, p > .05). Patients with ASD who underwent staged anterior–posterior spinal arthrodesis within 3 months after index surgery were similarly likely to experience functional improvement in the same timeframe as patients who underwent non-staged surgery. Patient satisfaction did not differ significantly between staged and non-staged groups. III.

OBJECTIVE The aim of this study was to compare all-cause reoperation rates and costs in nonelderly patients treated with anterior cervical discectomy and fusion (ACDF) with structural allograft versus synthetic cages for degenerative pathology. METHODS We queried a private claims database to identify adult patients ( ≤ 65 years) who underwent single-level ACDF in a hospital setting using either structural allograft or a synthetic cage (polyetheretherketone, metal, or hybrid device), from 2010 to 2016. The rate of all-cause reoperations at 2 years were compared between the 2 groups. Index hospitalization costs and 90-day complication rates were also compared. Significance was set at p < 0.05. RESULTS A total of 26,754 patients were included in the study. 11,514 patients (43%) underwent ACDF with structural allograft and 15,240 (57%) underwent ACDF with a synthetic cage. The patients in the allograft group were younger and more likely to be male. There was no significant difference between the 2 groups with respect to 90-day complications including: wound dehiscence, dysphagia, dysphonia, and hematoma/seroma. In the 2-year postoperative period, the synthetic cage group had a significantly higher rate of allcause reoperation compared to the allograft group (9.1% vs. 8.0%, p = 0.002). Index hospitalization costs were significantly higher in the synthetic cage group compared to those in the allograft group ($23,475 vs. $20,836, p < 0.001). CONCLUSION Structural allograft is associated with lower all-cause reoperation rates and lower index costs in nonelderly patients undergoing ACDF surgery for degenerative pathology. It is important to understand this data as we transition toward value-based care.

OBJECTIVE Lumbar discectomy is commonly performed for symptomatic lumbar disc herniation. We aimed to examine prescribing patterns and risk factors for chronic opioid use following lumbar discectomy. METHODS Using a private insurance claims database, patients were identified who underwent primary lumbar discectomy from 2010-2015 and had 1-year of continuous enrollment postoperatively. Patients were excluded with spinal fusion. The strength of opioid prescriptions was quantified using morphine milligram equivalents daily (MMED). Univariate and multivariate logistic regression models were built to examine risk factors associated with chronic postoperative opioid use. RESULTS A total of 5,315 patients were included in the study (mean age, 59 years; 50% female). 1,198 of patients (23%) used chronic opioids postoperatively. Chronic opioid use declined significantly from 27% in 2010 to 17% in 2015, p < 0.001. In addition, there were significantly fewer patients receiving high and very high-dose opioid prescriptions from 2010-2015, p < 0.001. The median duration that patients used opioids postoperatively was 211 days in 2010 (interquartile range [IQR], 29-356 days), and decreased significantly to 44 days (IQR, 10-294 days) in 2015. The strongest factors associated with chronic opioid use were preoperative opioid use (odds ratio [OR], 4.0), drug abuse (OR, 2.6), depression (OR, 1.6), surgery in the west (OR, 1.6) or south (OR, 1.6), anxiety (OR, 1.5), or 30-day readmission (OR, 1.4). CONCLUSION Chronic opioid use following primary lumbar discectomy has declined from 2010-2015. A variety of factors are associated with chronic opioid use. Preoperative recognition of some of these risk factors may aid in perioperative management and counseling.

The incidence of anterior cruciate ligament (ACL) reconstruction is increasing in the United States, particularly in the older athlete. Patients who undergo ACL reconstruction are at higher risk for undergoing total knee arthroplasty (TKA) later in life. TKA in patients with prior ACL reconstruction has been associated with longer operative time due in-part to difficulty with exposure and retained hardware. Outcomes after TKA in patients with prior ACL reconstruction are not well defined, with some reports showing increased rate of complications and higher risk of reoperation compared with routine primary TKA, but these results are based on small and nonrandomized cohorts. Future research is needed to determine whether graft choice or fixation technique for ACL reconstruction influences outcomes after subsequent TKA. Furthermore, whether outcomes are affected by choice of TKA implant design for patients with prior ACL reconstruction warrants further study. This review analyzes the epidemiology, operative considerations, and outcomes of TKA following ACL reconstruction.

Background Previous studies have found an association between functional status and outcomes following hip and knee arthroplasty. The purpose of this study was to evaluate the effect of dependent functional status on outcomes after total shoulder arthroplasty (TSA). Methods The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients who underwent primary TSA (anatomic or reverse) for glenohumeral osteoarthritis from January 1, 2011 to December 31, 2016. Patients whose preoperative functional status was dependent were compared with independent patients. Demographic data, length of hospital stay, and postoperative complications within 30 days were analyzed. Multivariable logistic regression was used to isolate the effect of functional status on postoperative complications and readmission. Results A total of 12,982 patients underwent primary TSA (anatomic or reverse) and 3.2% had a dependent functional status. Dependent patients had higher rate of comorbidities, higher mean American Society of Anesthesiologists class, longer hospital stays, and higher complication rates (including pneumonia, urinary tract infection, and blood transfusion). Logistic regression revealed that dependent functional status was an independent predictor for occurrence of any complication (odds ratio 2.0, P Conclusion Patients with dependent functional status preoperatively are at increased risk for short-term complications and readmission within 30 days following primary TSA. Level of evidence : Level III

A cost-utility analysis study.This study aims to evaluate the cost-utility of neoadjuvant teriparatide therapy in osteopenic patients undergoing adult spinal deformity (ASD) surgery.There is increasing evidence supporting preoperative use of anabolic agents such as teriparatide for preoperative optimization of ASD patients with poor bone density. However, such treatments are associated with added costs. To our knowledge, the cost-utility of teriparatide in osteopenic patients undergoing ASD surgery has not been established.A decision-analysis model was developed for a hypothetical 68-year-old female patient with osteopenia ( T score-1.0) undergoing a T11 to pelvis instrumented spinal fusion for ASD. A comprehensive literature review was conducted to create estimates for event probabilities, costs, and quality adjusted life years at each node. Key model assumptions were that administration of a 4-month preoperative teriparatide course reduced 2-year postoperative reoperation rates [for pseudarthrosis from 5% to 2.5% and for proximal junctional failure (PJF) from 15% to 5%]. Monte Carlo simulations were used to calculate the mean incremental cost utility ratio and incremental net monetary benefits. One-way sensitivity analysis was used to estimate the contribution of individual parameters to uncertainty in the model.Teriparatide was the favored strategy in 82% of the iterations. The mean incremental cost utility ratio for the teriparatide strategy was negative (higher net benefit, lower net cost), and lower than the willingness-to-pay threshold of $50,000 per quality adjusted life year. Teriparatide use was associated with a mean incremental net monetary benefit of $3,948. One-way sensitivity analysis demonstrated that the factors with the greatest impact on the model were the incidence of PJF in the no teriparatide group, the duration and monthly cost of treatment, and the cost of reoperation due to PJF.Neoadjuvant teriparatide is a cost-effective strategy to reduce postoperative complications in patients with osteopenia undergoing ASD surgery.

The primary objective of our systematic review and meta-analysis was to systematically compare the reported outcomes between laminectomy and laminectomy with fixation/fusion (LF) for the treatment of intradural extramedullary tumors (IDEMTs). Our secondary objective was to compare the outcomes between different laminectomy exposure techniques.PubMed and Embase were queried for literature on laminectomy and LF for IDEMTs. Reports of transforaminal approaches, interlaminar approaches, corpectomy, pediatrics patients, intramedullary tumors, technical studies, animal or cadaver studies, and literature reviews were excluded. The outcome measures recorded were pain, neurologic function, functional independence, cerebrospinal fluid leak, and wound infection. Where possible, the laminectomy technique (partial laminectomy [PL] vs. total laminectomy [TL]) was specified. Stata, version 17, was used for the fixed effects inverse variance meta-analysis.Of 1849 reports assessed, 17 were included. The meta-analysis revealed that laminectomy (PL or TL) resulted in higher rates of postoperative sagittal instability compared with LF (odds ratio, 1.81; P0.001). No differences in any other postoperative outcome were observed between laminectomy and LF (P = 0.44). The systematic review also revealed no differences in postoperative pain, neurologic function, or functional independence or disability between PL and TL. Some evidence suggested that TL might result in greater rates of sagittal instability compared with PL.No differences between LF, PL, or TL in pain, neurologic deficit, functional independence, cerebrospinal fluid leak, or wound infection were reported. Laminectomy had greater odds of sagittal instability compared with LF. Patients with preoperative sagittal instability requiring extensive removal of the posterior spinal column to achieve adequate resection of large tumors might benefit from LF.

Introduction:Opioid prescribing patterns play an important role in the opioid epidemic in the United States. The purpose of this study is to examine the trends and geographic variation in opioid prescribing patterns after anterior cruciate ligament (ACL) reconstruction.Hypothesis:Regional differences in opioid prescribing patterns after ACL reconstruction are present.Study Design:Descriptive epidemiology study.Level of Evidence:Level 4.Methods:The Truven Health MarketScan Commercial Claims database was used to analyze all patients with perioperative private insurance coverage who underwent ACL reconstruction from January 1, 2010, to November 31, 2017. Total number and morphine milligram equivalents per day (MMED) of opioid prescriptions were examined, and regional and statewide variation was assessed.Results:A total of 90,068 ACL reconstruction patients who underwent surgery between 2010 and 2017 were included in the study. Overall, 67% received an opioid prescription within 30 days of surgery and 17% received an opioid prescription ≥90 MMED. The West (20%) had the highest proportion of patients with an opioid prescription ≥90 MMED and the Northeast had the lowest (12%), P < 0.001. The number of opioid prescriptions as well as proportion of opioid prescriptions ≥90 MMED varied significantly by state, P < 0.001. There was a significant increase in number of opioid prescriptions from 2010 to 2017 (62% in 2010 and 83% in 2017; P < 0.001). A significant change in the proportion of patients being prescribed ≥90 MMED was also present ( P = 0.04; 15% in 2010, 17% in 2011, 17% 2012, 17% in 2013, 15% in 2014, 20% in 2015, 18% in 2016, and 15% in 2017).Conclusion:This study shows a trend of increasing opioid prescriptions and geographic variations in the amount and MMED of opioid prescriptions for patients undergoing ACL reconstruction. These data highlight several areas of improvement that state officials and national entities can use to help curb the opioid epidemic and underscore the importance of national guidelines for opioid prescribing.Clinical Relevance:Knowledge of prescribing patterns after specific procedures may help provide more direct insight and guidance to surgeons and patients regarding postoperative pain management.

Depression and anxiety are common psychiatric conditions among US adults, and anterior cervical discectomy and fusion (ACDF) is one of the most commonly performed spinal surgeries. Mental health conditions can affect physical health, and thus have the potential to contribute to adverse outcomes after spine surgery; however, a comprehensive assessment of long-term outcomes and the additive economic burden of these conditions in patients undergoing ACDF has not been well described.Our goal was to assess the associations between depression/anxiety and adverse outcomes and health-resource utilization after anterior cervical discectomy and fusion (ACDF).Retrospective database study.We retrospectively analyzed a private administrative health claims database to identify patients who underwent ACDF in the United States from 2010 to 2013. A total of 16,306 patients met our inclusion criteria. Mean (± standard deviation) patient age was 50±7.9 years. Approximately 4,800 patients (30%) had a depression diagnosis and 4,000 (25%) had a diagnosis of anxiety.The primary outcomes of interest were intensive care unit admission, multiday hospitalization, discharge disposition, 30- and 90-day hospital readmission, 1- and 2-year rates of revision surgery, and chronic postoperative opioid use. Secondary outcomes were 1- and 2-year total cumulative health care payments and cumulative postoperative opioid consumption.Regression models controlled for demographic and medical covariates, alpha=0.05.A preoperative diagnosis of depression was associated with higher odds of multiday hospitalization (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.01-1.19), 90-day readmission (OR 1.71, 95% CI 1.46-2.02), revision surgery within 2 years (OR 1.43 95% CI 1.16-1.76), and chronic postoperative opioid use (OR 1.58, 95% CI 1.45-1.72) and an increase of $5,915 in adjusted 2-year health care payments (p.001). Patients with a preoperative diagnosis of anxiety had higher odds of multiday hospitalization (OR 1.15, 95% CI 1.06-1.25), revision surgery within 2 years (OR 1.33, 95% CI 1.07-1.65), and chronic postoperative opioid use (OR 1.62, 95% CI 1.48-1.77) and an increase of $4,471 in adjusted 2-year health care payments (p.001). Neither anxiety nor depression was associated with intensive care unit admission, discharge disposition, 30-day readmission, revision surgery within 1 year, 1-year cumulative health care payments, or cumulative postoperative opioid consumption.Patients with preoperative diagnoses of depression or anxiety have a greater likelihood of adverse outcomes, increased opioid consumption, and increased cumulative health care payments after ACDF compared with patients without depression or anxiety.

STUDY DESIGN Retrospective database review. OBJECTIVE The aim of this study was to determine the incidence of Clostridium difficile infection (CDI) within 90 days following elective spine surgery; examine risk factors associated with its development; and evaluate the impact of CDI on postoperative outcomes. SUMMARY OF BACKGROUND DATA Although previous studies provided valuable insight into the rate of CDI following spine surgery and associated risk factors, to date no study has evaluated the role preoperative antibiotics use plays in the development of CDI, as well as its impact on 90-day outcomes. METHODS A retrospective database review of Humana patients ages 20 to 84 years who underwent elective spine surgery between 2008 and 2016 was conducted. Following exclusion criteria, the population was divided into patients who developed CDI within 90 days of surgery and those who did not. All risk factors and outcomes were analyzed using multivariate regression. RESULTS A total of 63,667 patients met study criteria. Ninety-day incidence of CDI was 0.68%. Notable medical risk factors (P

Retrospective review.To identify national trends in postoperative opioid prescribing practices after posterior spinal fusion (PSF) in patients with adolescent idiopathic scoliosis (AIS). Opioids are an important component of pain management after PSF for AIS. Given the national opioid crisis, it is important to understand opioid prescribing practices in these patients.Using a commercial prescription drug claims database, we identified AIS patients who underwent PSF from 2010 to 2016 and who were prescribed opioids postoperatively. An initial prescription at hospital discharge of ≥ 90 morphine milligram equivalents daily (MMED) was used to identify patients at risk of overdose according to the US Centers for Disease Control and Prevention (CDC) guidelines. Prescriptions for skeletal muscle relaxants were also identified. α = 0.05.We included 3762 patients (75% female) with a mean (± standard deviation) age of 15 ± 2.1 years. 56% of patients filled only 1 opioid prescription after discharge, and 44% had ≥ 1 refills. 91% of opioid prescriptions were for hydrocodone (median strength, 43 MMED; mean strength, 65 ± 270 MMED) or oxycodone formulations (median strength, 60 MMED; mean strength, 79 ± 174 MMED). 82% of prescriptions complied with CDC guidelines ( 90 MMED). Overall, 612 patients (16%) filled ≥ 1 prescription for skeletal muscle relaxants, the most common being cyclobenzaprine (45%) and methocarbamol (29%). The percentage of patients filling 1 prescription declined from 54% in 2010 to 31% in 2016 (p 0.001). The proportion of patients receiving prescriptions for ≥ 90 MMED was highest in the West (29%) and lowest in the South (16%) (p 0.001).Most opioid prescriptions after PSF in patients with AIS comply with CDC guidelines. Temporal and geographic variations show an opportunity for standardizing opioid prescribing practices in these patients.III.

Objective: The aim of the study was to compare trends and differences in preoperative and prolonged postoperative opioid use following spinal cord stimulator (SCS) implantation and to determine factors associated with prolonged postoperative opioid use. Methods: A database of private-payer insurance records was queried to identify patients who underwent a primary paddle lead SCS placement via a laminectomy (CPT-C3655) from 2008-2015. Our resulting cohort was stratified into those with prolonged postoperative opioid use, opioid use between 3- and 6-month postoperation, and those without. Multivariate logistic regression was used to determine the effect preoperative opioid use and other factors of interest had on prolonged postoperative opioid use. Subgroup analysis was performed on preoperative opioid users to further quantify the effect of differing magnitudes of preoperative opioid use. Results: A total of 2,374 patients who underwent SCS placement were identified. Of all patients, 1,890 patients (79.6%) were identified as having prolonged narcotic use. Annual rates of preoperative (p = 0.023) and prolonged postoperative narcotic use (p < 0.001) decreased over the study period. Significant independent predictors of prolonged postoperative opioid use were age < 65 years (odds ratio [OR], 1.52; p = 0.004), male sex (OR, 1.33; p = 0.037), preoperative anxiolytic (OR, 1.55; p = 0.004) and muscle relaxant (OR, 1.42; p = 0.033), and narcotic use (OR, 15.04; p < 0.001). Increased number of preoperative narcotic prescriptions correlated with increased odds of prolonged postoperative use. Conclusion: Patients with greater number of preoperative opioid prescriptions may not attain the same benefit from SCSs as patients with less opioid use. The most significant predictor of prolonged narcotic use was preoperative opioid use.

Economic modeling of data from a multicenter, prospective registry.The aim of this study was to analyze the cost utility of recombinant human bone morphogenetic protein-2 (BMP) in adult spinal deformity (ASD) surgery.ASD surgery is expensive and presents risk of major complications. BMP is frequently used off-label to reduce the risk of pseudarthrosis.Of 522 ASD patients with fusion of five or more spinal levels, 367 (70%) had at least 2-year follow-up. Total direct cost was calculated by adding direct costs of the index surgery and any subsequent reoperations or readmissions. Cumulative quality-adjusted life years (QALYs) gained were calculated from the change in preoperative to final follow-up SF-6D health utility score. A decision-analysis model comparing BMP versus no-BMP was developed with pseudarthrosis as the primary outcome. Costs and benefits were discounted at 3%. Probabilistic sensitivity analysis was performed using mixed first-order and second-order Monte Carlo simulations. One-way sensitivity analyses were performed by varying cost, probability, and QALY estimates (Alpha = 0.05).BMP was used in the index surgery for 267 patients (73%). The mean (±standard deviation) direct cost of BMP for the index surgery was $14,000 ± $6400. Forty patients (11%) underwent revision surgery for symptomatic pseudarthrosis (BMP group, 8.6%; no-BMP group, 17%; P = 0.022). The mean 2-year direct cost was significantly higher for patients with pseudarthrosis ($138,000 ± $17,000) than for patients without pseudarthrosis ($61,000 ± $25,000) (P 0.001). Simulation analysis revealed that BMP was associated with positive incremental utility in 67% of patients and considered favorable at a willingness-to-pay threshold of $150,000/QALY in52% of patients.BMP use was associated with reduction in revisions for symptomatic pseudarthrosis in ASD surgery. Cost-utility analysis suggests that BMP use may be favored in ASD surgery; however, this determination requires further research.2.

Background Cryoballoon ablation could induce stricture formation to achieve outlet and pouch reduction in patients regaining weight after Roux-en-Y gastric bypass (RYGB). This pilot study aimed to assess technical feasibility and short-term efficacy. Methods A retrospective chart review (January – November 2018) at two academic centers identified patients with weight regain post-RYGB, treated with cryoablation if pouch > 4 cm and/or outlet > 15 mm. Patients were scheduled for surveillance endoscopies at 8 weeks. Results 22 patients presented 10.5 years (SD 4.42) post-RYGB with weight regain of 30.9 kg (SD 13.7). Technical success was 89.5 % for outlet ablation and 93.0 % for pouch ablation. From baseline to 8 weeks, the outlet was reduced from 24.1 mm (95 % confidence interval [CI] 19.8 to 28.5) to 17.1 mm (95 %CI 13.1 to 21.1; P Conclusion Cryoablation appears technically feasible and effective for outlet and/or pouch reduction in the short term.

Study Design: Retrospective review of an administrative database. Objectives: The aim of our study was to investigate the distribution of spending for the entire episode of care among nonelderly, commercially insured patients undergoing elective, inpatient anterior cervical discectomy and fusion (ACDF) surgeries for degenerative cervical pathology. Methods: Using a private insurance claims database, we identified patients who underwent single-level, inpatient ACDF for degenerative spinal disease. Patients were selected using a combination of Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes. Entire episode of care was defined as 6-months before (preoperative) to 6 months after (postoperative) the surgical admission. Results: In our cohort containing 33 209 patients, perioperative median spending per patient (MSPP) within the year encompassing surgery totaled $37 020 (interquartile range [IQR] $28 363-$49 206), with preoperative, surgical admission, and postoperative spending accounting for 9.8%, 80.7%, and 9.5% of total spending, respectively. Preoperatively, MSPP was $3109 (IQR $1806-$5215), 48% of patients underwent physical therapy, and 31% underwent injections in the 6 months period prior to surgery. Postoperatively, MSPP was $1416 (IQR $398-$3962), and unplanned hospital readmission (6% incidence) accounted for 33% of the overall postoperative spending. Discharge to a nonhome discharge disposition was associated with higher postoperative spending ($14 216) compared with patients discharged home ($1468) and home with home care ($2903), P < .001. Conclusion: Understanding the elements and distribution of perioperative spending for the episode of care in patients undergoing ACDF surgery for degenerative conditions is important for health care planning and resource allocation.

Although prescribing opioid medication on a limited basis for postoperative pain control is common practice, few studies have focused on chronic opioid use following anterior cervical discectomy and fusion (ACDF).To determine the prevalence of and risk factors for chronic opioid use following one and two-level ACDF for degenerative cervical pathology.Retrospective cohort.Using an insurance claims database, we identified patients aged 18-64 who underwent one or two-level primary ACDF from 2010 to 2015 for degenerative cervical pathology.Opioid prescription strength at various timepoints pre- and postoperatively and development of chronic postoperative opioid use.Prescription opioid use was examined during the following periods: 90 days before 7 days preceding surgery (preoperative), 6 days preceding surgery to 90 days following surgery (perioperative) and from 91 to 365 days following surgery (postoperative). The primary outcome was chronic postoperative opioid use, defined as ≥120 days' supply of opioid prescriptions filled or ≥10 opioid prescriptions between 3 and 12 months postoperatively. Secondary outcomes were high-dose (90 morphine milligram equivalents [MME]/day) and very high-dose (200 MME/day) opioid prescriptions. A multivariate logistic model (area under the ROC curve 0.75, p.001) was built to predict long-term opioid use.Among 28,813 patients who underwent ACDF, most were female (55%) and underwent single-level ACDF (68%), with mean age of 50±8.0 years. Fifty-two percent of patients filled an opioid prescription in the preoperative period, 95% of patients filled a prescription in the perioperative period, and 39% of patients filled a prescription in the postoperative period. High-dose and very high-dose opioid prescriptions in the perioperative period were identified in 45% and 24% of patients, respectively, whereas 17% met criteria for chronic postoperative opioid use. The odds of chronic opioid use were highest in the Western US (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.3, 1.6). Duration of opioids prescribed was also highest in the Western US (median 111 days, interquartile range 11-336), p.001. Factors associated with the highest risk for chronic opioid use were preoperative opioid use (OR 5.7, 95% CI 5.3, 56.2), drug abuse (OR 3.5, 95% CI 2.6, 4.5), depression (OR 1.7, 95% CI 1.6, 1.9), anxiety (OR 1.5, 95% CI 1.4, 1.6), and surgery in the western region of the United States (OR 1.5, 95% CI 1.3, 1.6).Patients undergoing ACDF commonly receive high-dose opioid prescriptions after surgery, and certain patient factors increase risk for chronic opioid use following ACDF. Intervention focusing on patients with these factors is essential to reduce long-term use of prescription opioids and postoperative care.

Background Context Three-column osteotomy (3CO) is used to correct rigid adult spinal deformity. It presents risk of complications because it involves extensive osseous resection and spinal destabilization. Purpose Our purpose was to characterize the learning curve for performing 3CO in adult spinal deformity patients. Design Retrospective review. Patient Sample A surgical registry at a tertiary care center was used to identify 238 cases of 3CO for correction of adult spinal deformity by 1 surgeon between 2005 and 2014. Patients with at least 1 year of clinical and radiographic follow-up were included (n = 197) (mean duration of follow-up, 43 months; range, 12–121). Outcome Measures We quantified associations between surgeon experience and 1) estimated blood loss per vertebral level fused (EBL/VLF), 2) incidence of new neurologic deficits, 3) incidence of reoperation for instrumentation failure, 4) operative time in minutes, and 5) magnitude of correction at the level of the osteotomy. Methods The learning curve for binary outcomes was demonstrated using a LOWESS smoother plot of the probability of occurrence. Change in risk was calculated using a generalized linear model with link identity and binomial family. The learning curve for continuous variables was demonstrated using a scatter plot and a line of best fit based on linear regression analysis. Alpha = 0.05. Results EBL/VLF decreased by a mean of 19.7 mL (95% confidence interval [CI], 11.3–28.1) with each 10 cases (decrease of 388 mL/level fused by the end of the study period). The risk of a neurologic deficit declined by 7.98% (95% CI: 7.98%, 7.99%) with every 100 cases. The risk of reoperation declined by 1.99% (95% CI: 0.83%, 3.17%) with every 10 cases until the 100th case. After that point, there was no significant change in the probability of reoperation (p > 0.05). The magnitude of correction and operative time did not change with increasing surgeon experience (p > 0.05). Conclusion Incidence of reoperation for instrumentation failure, incidence of new neurological deficits, and estimated blood loss improved with increasing surgeon experience at performing 3CO. Most outcomes, except the risk of reoperation, improved through the last case.

A retrospective study.This study sought to characterize the incidence and timing of postoperative emergency department (ED) visits after common outpatient spinal surgeries performed at ambulatory surgery centers (ASCs) and at hospital outpatient departments (HOPDs).Outpatient spine surgery has markedly grown in popularity over the past decade. The incidence of ED visits after outpatient spine surgery is not well established.This study was a retrospective analysis of a large commercial claims insurance database of patients 65 years old and below. Patients who underwent single-level anterior cervical discectomy and fusion, laminectomy, and microdiscectomy were identified. Incidence, timing, and diagnoses associated with ED visits within the postoperative global period (90 d) after surgery were assessed.In total, 202,202 patients received outpatient spine surgery (19.1% in ASC vs. 80.9% in HOPD). Collectively, there were 22,198 ED visits during the 90-day postoperative period. Approximately 9.0% of patients had at least 1 ED visit, and the incidence varied by procedure: anterior cervical discectomy and fusion 9.9%, laminectomy 9.5%, and microdiscectomy 8.5% ( P0.0001). After adjusting for age, sex, and comorbidity index, the odds of at least 1 ED visit were higher among patients who received surgery at HOPD versus ASC for all 3 procedures. The majority (56.1%) ED visits occurred during the first month postoperatively; 30.8% (n=6841) occurred within the first week postoperatively, and 10.7% (n=2370) occurred on the same day as the surgery. Postoperative pain was the most common reason for ED visits.Among commercially insured patients who received outpatient spine surgery, the incidence of ED visits during the 90-day postoperative period was ~9%. Our results indicate opportunities for improved postoperative care planning after outpatient spinal surgery.

STUDY DESIGN: Retrospective review. OBJECTIVE: The primary aim was to compare length of stay (LOS) and discharge disposition of adult spinal deformity (ASD) patients undergoing surgery before and during the pandemic. Secondary aims were to compare the rates of 30-day complications, reoperations, readmissions, and unplanned emergency department (ED) visits. SUMMARY OF BACKGROUND DATA: ASD patients often require extended LOS and non-routine discharge. Given resource limitations during the Coronavirus Disease 2019 (COVID-19) pandemic and caution regarding hospital stays, surgeons modified standard postoperative protocols to minimize patient exposure. METHODS: We identified all patients who underwent elective thoracolumbar ASD surgery with more than or equal to five levels fusion at a tertiary care center during two distinct time intervals: July to December 2019 (Pre-COVID, N = 60) and July to December 2020 (During-COVID, N = 57). Outcome measures included LOS and discharge disposition (home vs. non-home), as well as 30-day major complications, reoperations, readmissions, and ED visits. Regression analyses controlled for demographic and surgical factors. RESULTS: Patients who underwent ASD surgery during the pandemic were younger (61 vs. 67 yrs) and had longer fusion constructs (nine vs. eight levels) compared with before the pandemic (P 

Retrospective.The purpose of this study was to assess trends in utilization rates of adult spinal deformity (ASD) surgery, as well as perioperative surgical metrics between Black and White patients undergoing operative treatment for ASD in the United States.Racial disparities in access to care, complications, and surgical selection have been shown to exist in the field of spine surgery. However, there is a paucity of data concerning racial disparities in the management of ASD patients.Adult patients undergoing ASD surgery from 2004 to 2014 were identified in the nationwide inpatient sample (NIS). Utilization rates, major complications rates, and length of stay (LOS) for Black patients and White patients were trended over time. Utilization rates were reported per 1,000,000 people and determined using annual census data among subpopulations stratified by race. All reported complication rates and prolonged hospital stay rates are adjusted for Elixhauser Comorbidity Index, income quartile by zip code, and insurance payer status.From 2004 to 2014, ASD utilization for Black patients increased from 24.0 to 50.9 per 1,000,000 people, whereas ASD utilization for White patients increased from 29.9 to 73.1 per 1,000,000 people, indicating a significant increase in racial disparities in ASD utilization (P-trend 0.001). There were no significant differences in complication rates or rates of prolonged hospital stay between Black and White patients across the time period studied (P 0.05 for both).Although Black and White patients undergoing ASD surgery do not differ significantly in terms of postoperative complications and length of hospital stay, there is a growing disparity in utilization of ASD surgery between White and Black patients from 2004 to 2014 in the United States. There is need for continued focus on identifying ways to reduce racial disparities in surgical selection and perioperative management in spine deformity surgery.Level of Evidence: 3.

Study Design: Retrospective review. Objective: To use predictive modeling and machine learning to identify patients at risk for venous thromboembolism (VTE) following posterior lumbar fusion (PLF) for degenerative spinal pathology. Methods: Patients undergoing single-level PLF in the inpatient setting were identified in the National Surgical Quality Improvement Program database. Our outcome measure of VTE included all patients who experienced a pulmonary embolism and/or deep venous thrombosis within 30-days of surgery. Two different methodologies were used to identify VTE risk: 1) a novel predictive model derived from multivariable logistic regression of significant risk factors, and 2) a tree-based extreme gradient boosting (XGBoost) algorithm using preoperative variables. The methods were compared against legacy risk-stratification measures: ASA and Charlson Comorbidity Index (CCI) using area-under-the-curve (AUC) statistic. Results: 13, 500 patients who underwent single-level PLF met the study criteria. Of these, 0.95% had a VTE within 30-days of surgery. The 5 clinical variables found to be significant in the multivariable predictive model were: age > 65, obesity grade II or above, coronary artery disease, functional status, and prolonged operative time. The predictive model exhibited an AUC of 0.716, which was significantly higher than the AUCs of ASA and CCI (all, P < 0.001), and comparable to that of the XGBoost algorithm ( P > 0.05). Conclusion: Predictive analytics and machine learning can be leveraged to aid in identification of patients at risk of VTE following PLF. Surgeons and perioperative teams may find these tools useful to augment clinical decision making risk stratification tool.

The AHRQ (Agency for Healthcare Research and Quality) has requested the correction of the result Tables 1–3 of this study: All stated numbers below 10 shall be modified to read “

BACKGROUND The incidence of emergency department (ED) visits after posterior spinal fusion (PSF) in adolescent idiopathic scoliosis (AIS) patients is not well known. We hypothesize that the majority of ED visits are related to constipation and pain issues, and are not for serious complications. METHODS Using a private insurance claims database, we identified AIS patients aged 10 to 21 years who underwent PSF from 2010 to 2015. Patients were excluded for diagnoses of neuromuscular or syndromic scoliosis. ED visits that occurred within the 6-month postoperative period were identified. The diagnoses present at these visits were pooled and analyzed, in addition to insurance payments associated with these visits. Significance was set at P=0.05. RESULTS A total of 5934 patients met inclusion criteria. Mean age was 14.4±2.2 years, and 75% of the patients were girls. A total of 577 (9.7%) patients had at least 1 ED visit in the 6-month postoperative period, whereas 92 (1.6%) had 2 ED visits and 19 (0.3%) had 3 or more ED visits. The median time to ED visits was 33 days after surgery. Independent risk factors for ED visits were: older age, and greater levels fused (P