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Symptomatic postoperative epidural hematomas are rare, with an incidence of 0.10% to 0.69%. Risk factors have varied in the literature, but multiple studies have reported advanced age, preoperative or postoperative coagulopathy, and multilevel laminectomy as risk factors for hematoma. The role of pharmacologic anticoagulation after spine surgery remains unclear, but multiple studies suggest it can be done safely with a low risk of epidural hematoma. Prophylactic suction drains have not been found to lower hematoma incidence. Most symptomatic postoperative epidural hematomas present within the first 24 to 48 hours after surgery but can present later. Diagnosis of a symptomatic hematoma requires correlation of clinical signs and symptoms with a compressive hematoma on MRI. Patients will usually first complain of a marked increase in axial pain, followed by radicular symptoms in the extremities, followed by motor weakness and sphincter dysfunction. An MRI should be obtained emergently, and if it confirms a compressive hematoma, surgical evacuation should be carried out as quickly as possible. The prognosis for neurologic improvement after evacuation depends on the time delay and the degree of neurologic impairment before evacuation.

OBJECTIVELumbar fusion can lead to significant improvements in patient-reported outcomes (PROs) in patients with degenerative conditions. It is unknown whether the presence of hip or knee arthritis confounds the responses of patients to low-back–specific PROs. This study examined PROs with lumbar fusion in patients with concomitant lower-extremity arthritis. The purpose of the current study was to examine whether patients with significant lower-extremity arthritis who undergo lumbar fusion achieve similar improvements in low-back–specific PROs compared to patients without lower-extremity arthritis.METHODSPatients were identified from a prospectively enrolled multicenter registry of patients undergoing lumbar fusion surgery for degenerative conditions. Two hundred thirty patients identified with lumbar fusion and who also had concomitant lower-extremity arthritis were propensity matched to 233 patients who did not have lower-extremity arthritis based on age, BMI, sex, smoking status, American Society of Anesthesiologists grade, number of levels fused, and surgical approach. One-year improvement in PROs, numeric rating scales (0–10) for back and leg pain, and the Oswestry Disability Index and EuroQol-5D scores were compared for patients with and without lower-extremity arthritis.RESULTSBaseline demographics and preoperative outcome measures did not differ between the two propensity-matched groups with 110 cases each. Patients with concomitant lower-extremity arthritis achieved similar improvement in health-related quality-of-life measures to patients without lower-extremity arthritis, with no significant differences between the groups (p > 0.10).CONCLUSIONSThe presence of lower-extremity arthritis does not adversely affect the results of lumbar fusion in properly selected patients. Patients with lower-extremity arthritis who undergo lumbar fusion can achieve meaningful improvement in PROs similar to patients without arthritis.

BACKGROUND: The opioid epidemic is at epic proportions currently in the United States. Exposure to opioids for surgery and subsequent postoperative pain management is a known risk factor for opioid dependence. In addition, opioids can have a negative impact on multiple aspects including clinical outcomes, length of hospital stay, and overall cost of care. Thus, the greatest effort to reduce perioperative opioid use is necessary and a multimodal pain control (MMPC) has been gaining popularity. However, its efficacy in spine surgery is not well known. We aimed to evaluate the efficacy of a MMPC protocol in patients undergoing lumbar single-level anterior lumbar interbody fusion (ALIF). METHODS: This is a retrospective comparative study. From a prospective, single-surgeon, surgical database, consecutive patients undergoing single-level ALIF with or without subsequent posterior fusion for degenerative lumbar conditions were identified before and after initiation of the MMPC protocol. The MMPC protocol consisted of a preoperative oral regimen of cyclobenzaprine (10 mg), gabapentin (600 mg), acetaminophen (1 g), and methadone (10 mg). Postoperatively they received a bilateral transverse abdominis plane block with 0.5% Ropivacaine prior to extubation. We compared in-hospital opioid consumption between the MMPC and non-MMPC cohorts as well as baseline demographic, the length of hospital stay, cost, and rate of postoperative ileus. Opioid consumption was calculated and normalized to the morphine milligram equivalents (MMEs). RESULTS: In total, 68 patients in the MMPC cohort and 39 in the non-MMPC cohort were identified. There was no difference in baseline demographics including sex, body mass index, smoking status, or preoperative opioid use between the two groups. Although there was no difference in the MMEs on the day of surgery (58.5 vs. 66.9, P=0.387), cumulative MMEs each day after surgery was significantly lower in the MMPC cohort, with final cumulative MMEs being reduced by 62% (120.2 vs. 314.8, P

OBJECTIVEUnexpected nonhome discharge causes additional costs in the current reimbursement models, especially to the payor. Nonhome discharge is also related to longer length of hospital stay and therefore higher healthcare costs to society. With increasing demand for spine surgery, it is important to minimize costs by streamlining discharges and reducing length of hospital stay. Identifying factors associated with nonhome discharge can be useful for early intervention for discharge planning. The authors aimed to identify the drivers of nonhome discharge in patients undergoing 1- or 2-level instrumented lumbar fusion.METHODSThe electronic medical records from a single-center hospital administrative database were analyzed for consecutive patients who underwent 1- to 2-level instrumented lumbar fusion for degenerative lumbar conditions during the period from 2016 to 2018. Discharge disposition was determined as home or nonhome. A logistic regression analysis was used to determine associations between nonhome discharge and age, sex, body mass index (BMI), race, American Society of Anesthesiologists grade, smoking status, marital status, insurance type, residence in an underserved zip code, and operative factors.RESULTSA total of 1502 patients were included. The majority (81%) were discharged home. Factors associated with a nonhome discharge were older age, higher BMI, living in an underserved zip code, not being married, being on government insurance, and having more levels fused. Patients discharged to a nonhome facility had longer lengths of hospital stay (5.6 vs 3.0 days, p < 0.001) and significantly increased hospital costs ($21,204 vs $17,518, p < 0.001).CONCLUSIONSIncreased age, greater BMI, residence in an underserved zip code, not being married, and government insurance are drivers for discharge to a nonhome facility after a 1- to 2-level instrumented lumbar fusion. Early identification and intervention for these patients, even before admission, may decrease the length of hospital stay and medical costs.

OBJECTIVEPosterior fixation with interbody cage placement can be accomplished via numerous techniques. In an attempt to expedite recovery by limiting muscle dissection, midline lumbar interbody fusion (MIDLIF) has been described. More recently, the authors have developed a robot-assisted MIDLIF (RA-MIDLIF) technique. The purpose of this study was to compare the index episode-of-care (iEOC) parameters between patients undergoing traditional open transforaminal lumbar interbody fusion (tTLIF), MIDLIF, and RA-MIDLIF.METHODSA retrospective review of a prospective, multisurgeon surgical database was performed. Consecutive patients undergoing 1- or 2-level tTLIF, MIDLIF, or RA-MIDLIF for degenerative lumbar conditions were identified. Patients in each cohort were propensity matched based on age, sex, smoking status, BMI, diagnosis, American Society of Anesthesiologists (ASA) class, and number of levels fused. Index EOC parameters such as length of stay (LOS), estimated blood loss (EBL), operating room (OR) time, and actual, direct hospital costs for the index surgical visit were analyzed.RESULTSOf 281 and 249 patients undergoing tTLIF and MIDLIF, respectively, 52 cases in each cohort were successfully propensity matched to the authors’ first 55 RA-MIDLIF cases. Consistent with propensity matching, there was no significant difference in age, sex, BMI, diagnosis, ASA class, or levels fused. Spondylolisthesis was the most common indication for surgery in all cohorts. The mean total iEOC was similar across all cohorts. Patients undergoing RA-MIDLIF had a shorter average LOS (1.53 days) than those undergoing either MIDLIF (2.71 days) or tTLIF (3.58 days). Both MIDLIF and RA-MIDLIF were associated with lower EBL and less OR time compared with tTLIF.CONCLUSIONSDespite concerns for additional cost and time while introducing navigation or robotic technology, a propensity-matched comparison of the authors’ first 52 RA-MIDLIF surgeries with tTLIF and MIDLIF showed promising results for reducing OR time, EBL, and LOS without increasing cost.

OBJECTIVEThe midline transforaminal lumbar interbody fusion (MIDLIF) using cortical screw fixation is a novel, minimally invasive procedure that may offer enhanced recovery over traditional open transforaminal lumbar interbody fusion (TLIF). Little information is available regarding the comparative cost-effectiveness of the MIDLIF over conventional TLIF. The purpose of this study was to compare cost-effectiveness of minimally invasive MIDLIF with open TLIF.METHODSFrom a prospective, multisurgeon, surgical database, a consecutive series of patients undergoing 1- or 2-level MIDLIF for degenerative lumbar conditions was identified and propensity matched to patients undergoing TLIF based on age, sex, smoking status, BMI, diagnosis, American Society of Anesthesiologists Physical Status Classification System (ASA) class, and levels fused. Direct costs at 1 year were collected, including costs associated with the index surgical visit as well as costs associated with readmission. Improvement in health-related quality of life was measured using EQ-5D and SF-6D.RESULTSOf 214 and 181 patients undergoing MIDLIF and TLIF, respectively, 33 cases in each cohort were successfully propensity matched. Consistent with propensity matching, there was no difference in age, sex, BMI, diagnosis, ASA class, smoking status, or levels fused. Spondylolisthesis was the most common indication for surgery in both cohorts. Variable direct costs at 1 year were $2493 lower in the MIDLIF group than in the open TLIF group (mean $15,867 vs $17,612, p = 0.073). There was no difference in implant (p = 0.193) or biologics (p = 0.145) cost, but blood utilization (p = 0.015), operating room supplies (p < 0.001), hospital room and board (p < 0.001), pharmacy (p = 0.010), laboratory (p = 0.004), and physical therapy (p = 0.009) costs were all significantly lower in the MIDLIF group. Additionally, the mean length of stay was decreased for MIDLIF as well (3.21 vs 4.02 days, p = 0.05). The EQ-5D gain at 1 year was 0.156 for MIDLIF and 0.141 for open TLIF (p = 0.821). The SF-6D gain at 1 year was 0.071 for MIDLIF and 0.057 for open TLIF (p = 0.551).CONCLUSIONSCompared with patients undergoing traditional open TLIF, those undergoing MIDLIF have similar 1-year gains in health-related quality of life, with total direct costs that are $2493 lower. Although the findings were not statistically significant, minimally invasive MIDLIF showed improved cost-effectiveness at 1 year compared with open TLIF.

Background In 2011, studies suggested that complications and cancer rates associated with bone morphogenetic protein (BMP) were greater than previously reported. However, later studies reported complication rates similar to prior literature and no increased cancer rate. We evaluated the pattern of clinical utilization of BMP in posteriorly based lumbar fusion by comparing two periods: 2002-2004 and 2017-2019. Methods Patients who received BMP from 2002-2004 (Early) and 2017-2019 (Late) from a single multi-surgeon institution who had a lumbar fusion were identified. One hundred patients from each cohort were randomly selected. Mean total BMP used at each level and the proportion of BMP placed in the interbody space versus posterolateral gutters were evaluated. Results In the transforaminal lumbar intebody fusion (TLIF) cohort, the total BMP dose in the Late group (6.15 mg) was nearly half of that used in the Early group (12.04 mg, p

Background: Cortical bone trajectory (CBT) screws have been recently described as a method of lumbosacral fixation. These screws are typically inserted under fluoroscopic guidance with a medial-to-lateral trajectory in the axial plane and a caudal-to-cephalad trajectory in the sagittal plane. In an effort to reduce surgeon radiation exposure and improve accuracy, CBT screws may be inserted under navigation with intraoperative cone beam computed tomography (CT). However, the accuracy of CBT screw placement under intraoperative navigation has yet to be assessed in the literature. The purpose of the study was to evaluate the accuracy of CBT screw placement using intraoperative cone beam CT navigation. Methods: One hundred and thirty-four consecutive patients who underwent CBT fixation with 618 screws under intraoperative navigation were analyzed from May 2016 through May 2018. Screws were placed by one of three senior spine surgeons using the Medtronic O-Arm Stealth Navigation. Screw position and accuracy were assessed on intraoperative and postoperative CT scans using 2D and 3D reconstructions with VitreaCore software. Results: The majority of surgeries were primary cases (73.1%). The mean age at the time of surgery was 61.5±10.0 years and the majority of patients were female (61.2%). Most patients underwent surgery for a diagnosis of degenerative spondylolisthesis (47.8%) followed by mechanical collapse with foraminal stenosis (22.4%). Ten violations of the vertebral cortex were noted with an average breach distance of 1.0±0.7 mm. Three breaches were lateral (0.5%) and seven were medial (1.1%). The overall navigated screw accuracy rate was 98.3%. The accuracy to within 1 mm of error was 99.2%. There were no intra-operative neurologic, vascular, or visceral complications related to the placement of the CBT screws. Conclusions: CBT screw fixation under an intraoperative cone beam CT navigated insertion technique is safe and reliable. Despite five breaches greater than 1mm, there were no complications related to the placement of the CBT screws in this series.

Background context Patients undergoing single-level posterior lumbar decompression and fusion (PLDF) usually do not need transfusions. However, patients undergoing two or three-level PLDF occasionally require transfusion postoperatively even when estimated blood loss (EBL) or blood loss from drains appears acceptable. Estimating the volume of HBL is critical in perioperative fluid management. Purpose To determine the volume of hidden blood loss (HBL) in 2- or 3- level PLDF. Study Design Single center, multi-surgeon, secondary analysis from a prospective randomized clinical trial of cell-saver use. Patient Sample Patients enrolled in a prospective randomized trial of cell-saver undergoing two- or three-level PLDF were included in this analysis. Methods Total blood loss was calculated using four estimation formulas including Bourke's, Gross’, Camarasa's, and Lopez-Picado's formulas. HBL was determined by subtracting the visible loss (EBL and blood loss from drains) from the calculated total blood loss. Results A total of 89 patients (36 males, mean age 62 years) were included. Seventy-five patients underwent open two-level fusion while 14 had three-level fusions. Intervertebral fusion was performed in 20 patients. Mean surgical time was 261 minutes, and EBL was 685 ml. Mean blood loss from drains was 824 ml. Seventy patients received allogenic blood while 47 Cell Saver blood reinfused intraoperatively. Hidden blood loss was calculated to be 678 ml, 963 ml, 1267 ml, and 819 ml using each formula. Conclusions HBL following two or three-level PLDF was substantial and more than EBL. Postoperative management of blood loss should take HBL into account.

Study Design: Medicare database analysis. Objective: The purpose of this study was to investigate whether neurologic disorders represent a risk factor for revision after lumbar spine surgery. Methods: Patients who underwent lumbar spine surgery were identified from 5% Medicare Part B claims between 2005 and 2008. Cox regression analysis was used to evaluate risk factors for revision within the 7 years after the index lumbar surgery. Covariates included age, gender, race, census region, Medicare buy-in status, Charlson score, year, prior lumbar fusion within 2 years of index surgery, prior diagnosis of cervical spondylotic myelopathy treated with or without cervical spine surgery, and diagnoses of other neuromuscular conditions. Results: Of 8665 cases who had decompression only, 401 (5%) had a revision within 7 years after the index surgery. Factors predictive of revision were prior lumbar fusion (hazard ratio [HR] = 2.78, confidence interval [CI] = 1.43-5.37, P = .002) and being female (HR = 1.61, CI = 1.31-1.97, P < .001). Of 5501 cases who had a decompression and fusion, 752 (14%) had a revision surgery within 7 years after the index surgery. Factors predictive of revision were the presence of a neurologic disorder (HR = 1.24, CI = 1.05-1.46, P = .010), prior lumbar fusion (HR = 3.09, CI = 2.05-4.63, P < .001), and being female (HR = 1.35, CI = 1.15-1.57, P < .001). Conclusions: An increase in revision rate ( P = 0.01, HR = 1.24) was seen in patients with neurologic disorders undergoing lumbar decompression and fusion, although not for patients undergoing decompression alone. This suggests an opportunity to improve clinical outcome and reduce revision rate through improved surgical decision making or treatment of the neurologic disorder.

Study Design Prospective observational cohort. Objectives To examine the cost-effectiveness of IntraOperative ElectroMyeloGraphy (IO-EMG) by evaluating how often an abnormal IO-EMG signal changed the surgeon’s surgical plan, or replaced a pedicle screw either intra-operatively or as a second unplanned surgery. Methods Patients undergoing instrumented posterolateral lumbar fusion were monitored with intraoperative triggered EMG’s. Pedicle screws were placed freehand from L1 to S1 by attending physicians and fellows. Concern for pedicle breach was a screw stimulationResults There were 145 cases with a total of 725 pedicle screws placed. Mean age was 57.8 ± 14.2 yrs, OR time was 238 ± 95 minutes, EBL was 426.8 ± 354.3cc. Mean number of surgical levels fused was 2.7 ± 1.1. 686 (95%) screws stimulated at >10 mA and 39 (5%) screws stimulated at Conclusions Only 1% of the 725 lumbar pedicle screws placed in 8 of 145 cases required repositioning. Due to the infrequency of pedicle wall breaches and the cost of ION, the utility of this modality in straightforward lumbar fusions should be critically evaluated.

Background With the current opioid crisis, as many as 38% of patients are still on opioids one year after elective spine surgery. Identifying drivers of in-hospital opioid consumption may decrease subsequent opioid dependence. We aimed to identify the drivers of in-hospital opioid consumption in patients undergoing 1-2-level instrumented lumbar fusions. Methods This is a retrospective cohort study. Electronic medical record analysts identified consecutive patients undergoing 1-2 level instrumented lumbar fusions for degenerative lumbar conditions from 2016 to 2018 from a single-center hospital administrative database. Oral, intravenous, and transdermal opioid dose administrations were converted to morphine milligram equivalents (MME). Linear regression analysis was used to determine associations between postoperative day (POD) 4 cumulative in-hospital MMEs and the patients' baseline characteristics including body mass index (BMI), race, American Society of Anesthesiologists (ASA) grade, smoking status, marital status, insurance type, zip code, number of fused levels, approach and preoperative opioid use. Results A total of 1,502 patients were included. The mean cumulative MMEs at POD 4 was 251.5. Linear regression analysis yielded four drivers including younger age, preoperative opioid use, current smokers and more levels fused. There were no associations with surgical approach, zip code, ASA grade, marital status, BMI, race or insurance type. Conclusions Use of preoperative opioids and smoking are modifiable risk factors for higher in-hospital opioid consumption and can be targets for intervention prior to surgery in order to decrease in-hospital opioid use.

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.

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.

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.

Spine is one subject evaluated by the Orthopaedic In-Training Examination. The purpose of our study was to analyze all spine-related questions on the OITE to determine the most commonly tested spine topics, as well as the level of evidence in cited references, to help guide resident preparation for future examinations. The OITE was analyzed from 2013 to 2017 for number of spine questions, subject matter, anatomy, and use of diagnostic imaging. The preferred responses were reviewed for journal article references and corresponding levels of evidence for each citation. The average number of spine questions on the OITE was approximately 25 (9.0% of the exam) with a focus on cervical spine (7.8; 31.5%) and lumbar spine (9.8; 39.5%). At least one type of diagnostic image accompanied 18.4 questions (74.2%), with magnetic resonance imaging being the most common modality (50.0%). Degenerative diseases (10.8; 43.5%) and trauma (7.0; 28.2%) made up the majority. The most commonly cited journals were Spine (21.5%), Journal of the American Academy of Orthopedic Surgeons (20.8%), Spine Journal (8.4%), and Journal of Bone and Joint Surgery (8.4%). Review articles made up an average of 27.4 citations annually (49.5%). Level I evidence investigations were cited 3.4 times per examination. Developing a study plan centered on review articles as well as on high-yield topics should lead to optimal preparation for residents on the OITE.

BACKGROUND CONTEXT Recent studies suggest as much as 25% of patients undergoing spine surgery are still on opioids two years later. In response, we developed protocols to minimize opioid consumption following elective spine surgery. Our goal was to evaluate patients undergoing single-level Anterior Lumbar Interbody Fusions (ALIF ± posterior fixation) on MMPC compared to patients who were not (nonMMPC). PURPOSE To determine if the combination of an oral preoperative pain cocktail with transverse abdominis plane (TAP) block (multi-modal pain control: MMPC) will reduce length of stay (LOS), ileus, and in-hospital opioid consumption. STUDY DESIGN/SETTING Retrospective chart review. PATIENT SAMPLE Consecutive patients undergoing single-level ALIF for degenerative lumbar conditions by a single-surgeon. OUTCOME MEASURES Length of stay (LOS), incidence of ileus and in-hospital opioid consumption. METHODS A retrospective review of a prospective, single-surgeon, surgical database was utilized for consistency in technique. Consecutive patients undergoing single-level ALIF for degenerative lumbar conditions were identified before and after initiation of the MMPC. The MMPC consisted of a preop oral regimen of cyclobenzaprine (10mg), gabapentin (600mg), acetaminophen (1g) and methadone (10mg). Postoperatively they received a bilateral transverse abdominis plane (TAP) block with 0.5% Ropivicaine. Our primary outcome was total, in-hospital opioid consumption (morphine milligram equivalents: MME). RESULTS There were 68 patients in the MMPC cohort and 39 in the nonMMPC cohort. There was no difference in baseline demographics such as sex, BMI, smoking, or preoperative opioid use between the two groups. The MMPC cohort was older (56.7 vs 51.1 years, p=0.026). Similar rates of ileus (4 vs 6, p=0.102), no difference in LOS (3.8 vs 4.5, p=0.246) and no difference in index hospital costs was found. Although there was no difference in day of surgery MMEs (58.5 vs 68.9, p=0.387), cumulative MMEs each day after surgery was significantly lower in the MMPC cohort, with final cumulative MMEs being reduced by 62% (120.2 vs 314.8, p CONCLUSIONS The use of a MMPC regimen in patients undergoing single-level ALIF for degenerative conditions reduced opioid consumption starting on POD 1, resulting in a cumulative reduction of 62%. Further research should strive to minimize opioid use and the downstream effects. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Previous studies suggest that a postoperative symptom state with Oswestry Disability Index (ODI)≤20 and pain Numeric Rating Scales (NRS)≤2 following surgery for lumbar degenerative conditions are reasonable thresholds for best outcomes in which patients will be unlikely to seek additional medical care or require additional health-care resources. PURPOSE To identify prognostic factors that predict a “best outcome,” defined as postoperative ODI≤20 and pain NRS≤2 following fusion for lumbar degenerative conditions. STUDY DESIGN Longitudinal observational cohort. PATIENT SAMPLE A total of 396 patients from a single site enrolled in the Quality Outcomes Database who underwent fusion for lumbar degenerative conditions. Outcome Measures Oswestry Disability Index, Back and Leg Pain NRS (0–10). METHODS Collected and analyzed variables included age, sex, body mass index, American Society of Anesthesia grade, number of surgical levels, surgical time, preoperative ODI, preoperative back pain, preoperative leg pain, workmen compensation status, surgical approach, smoking status, and principal diagnosis. RESULTS A total of 74 patients (19%) reported a minimal symptom state at 1-year postoperative (ODI≤20, back pain NRS≤2, and leg pain NRS≤2) and were included in the best outcomes group. Patients in the best outcomes group were older (62 vs. 57 years, p=.001), had lower preoperative ODI (43 vs. 56, p=.000), lower preoperative back pain (6.5 vs. 7.5, p=.000). They had fewer surgical levels (1.25 vs. 1.47, p=.005) and shorter operative times [OR] times (208 vs. 241 minutes, p=.002). They were more likely to have a preoperative diagnosis of spondylolisthesis or disc herniation and less likely to have a diagnosis of adjacent segment disease or mechanical disc collapse (p=.001). Stepwise forward regression analysis revealed diagnosis (p=.023, OR=0.75), age (p=.000, OR=1.04), baseline ODI (p=.000, OR=0.96), and number of levels (p=.019, OR=0.53) as predictive variables. CONCLUSION Achieving a minimal symptom state, defined here as a postoperative ODI≤20 and pain NRS≤2, following fusion for lumbar degenerative conditions is more likely in an older patient with a lower baseline ODI undergoing a single level lumbar fusion for spondylolisthesis.

OBJECTIVEThe goal of this study was to determine efficacy and cost-effectiveness of Cell Saver in 2- and 3-level lumbar decompression and fusion.METHODSPatients seen at a tertiary care spine center who were undergoing a posterior 2- or 3-level lumbar decompression and fusion were randomized to have Cell Saver used during their surgery (CS group, n = 48) or not used (No Cell Saver [NCS] group, n = 47). Data regarding preoperative and postoperative hemoglobin and hematocrit, estimated blood loss, volume of Cell Saver blood reinfused, number of units and volume of allogeneic blood transfused intraoperatively and postoperatively, complications, and costs were collected. Costs associated with Cell Saver use were calculated based on units of allogeneic blood transfusions averted.RESULTSDemographics and surgical parameters were similar in both groups. The mean estimated blood loss was similar in both groups: 612 ml in the CS group and 742 ml in the NCS group. There were 53 U of allogeneic blood transfused in 29 patients in the NCS group at a total blood product cost of $67,688; and 38 U of allogeneic blood transfused in 16 patients in the CS group at a total blood cost of $113,162, resulting in a cost of $3031 per allogeneic blood transfusion averted using Cell Saver.CONCLUSIONSCell Saver use produced lower rates of allogeneic transfusion but was found to be more expensive than using only allogeneic blood for 2- and 3-level lumbar degenerative fusions. This increased cost may be reasonable to patients who perceive that the risks associated with allogeneic transfusions are unacceptable.■ CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: randomized controlled trial; evidence: class III.

BACKGROUND CONTEXT Posterior fixation with interbody cage placement can be accomplished via numerous techniques. In attempts to expedite recovery by limiting muscle dissection, the midline interbody fusion (MIDLIF) has been described. More recently, we have developed a robotic-assisted MIDLIF (RA-MIDLIF) technique. Introduction of new technology can potentially be expensive and burdensome. PURPOSE The purpose of this study was to compare index episode of care parameters between patients undergoing either traditional open TLIF (tTLIF), MIDLIF, or RA-MIDLIF. STUDY DESIGN/SETTING Retrospective review of a prospective, multisurgeon, surgical database. PATIENT SAMPLE Consecutive patients undergoing 1- or 2- level RA-MIDLIF, tTLIF or MIDLIF. OUTCOME MEASURES Estimated blood loss (EBL), operative tme (OR Time), length of stay (LOS), total direct hospital cost. METHODS A retrospective review of a prospective, multisurgeon, surgical database was utilized. Consecutive patients undergoing 1- or 2-level RA-MIDLIF for degenerative lumbar conditions were identified and propensity-matched based on age, sex, smoking status, BMI, ASA grade and levels fused to patients undergoing tTLIF or MIDLIF. LOS, EBL, OR Time and direct hospital cost for the index surgical admission were compared. RESULTS Of 55 RA-MIDLIF cases identified, 52 were successfully propensity-matched to patients undergoing tTLIF or MIDLIF. Consistent with propensity matching, there was no difference in age, sex, BMI, ASA grade, smoking status or levels fused. The mean direct hospital cost was similar across all cohorts. Patients undergoing RA-MIDLIF had a shorter average LOS (1.53 days) compared to either MIDLIF (2.71 days) or TLIF (3.58 days). Both MIDLIF and RA-MIDLIFs had lower EBL and less OR time compared to both tTLIF. CONCLUSIONS Despite concerns for additional cost and time while introducing navigation or robotic technology, a propensity-matched comparison of our first 52 robotic-assisted MIDLIF surgeries compared to tTLIF and MIDLIF showed promising results for reducing OR time, EBL, LOS and without increasing cost. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Background Context Transforaminal lumbar interbody fusion (TLIF) and dual-approach anteroposterior (AP) are common techniques to achieve circumferential fusion for lumbar spondylolisthesis. It is unclear which approach is more cost-effective. Purpose Our goal was to determine the incremental cost-effectiveness ratio (ICER) by calculating the cost per quality-adjusted life year (QALY) for each approach. Study Design/Setting This study is a propensity-matched cost-effectiveness comparison. Patient Sample Patients with lumbar spondylolisthesis undergoing single-level AP fusion or TLIF and enrolled in a prospective observational surgical database were included in this study. Outcome Measures The outcome measures in this study were the Oswestry Disability Index (ODI) and the Short Form-6D (SF-6D). Methods From a prospective surgical database, patients with lumbar spondylolisthesis undergoing single-level AP fusion were propensity matched to a TLIF cohort based on age, gender, body mass index, smoking status, workers compensation, preoperative ODI, and back and leg pain numeric scores. Quality-adjusted life years gained were determined using baseline and 1- and 2-yearpostoperative SF-6D scores. Cost was calculated from actual, direct hospital costs and included subsequent postsurgical costs (epidural spinal injections, spine-related emergency department visits, readmissions, and revision surgery). Results Thirty-one cases of AP fusions were identified and propensity matched to 31 TLIF patients. Patients undergoing TLIF had a shorter mean operative time (270 vs. 328 minutes, p=.039) but no difference in estimated blood loss (526 vs. 548 cc, p=.804) or hospital length of stay (4.5 vs. 6.1 days, p=.146). Quality-adjusted life years gained at 2 years were also similar (0.140 vs. 0.130, p=.672). The mean index surgery and the total 2-year costs were lower for TLIF compared with AP (index: $29,428 vs. $31,466; final: $30,684 vs. $331,880). As overall costs were lower and QALYs gained were similar for TLIF compared with AP fusion, TLIF was the dominant intervention with an ICER of $116,327. Conclusions Under our study parameters, surgical treatment of lumbar spondylolisthesis with TLIF is more cost-effective compared with AP fusion. Because of the short-term follow-up, the longevity of this should be further investigated.

The objective of this chapter is to discuss the decision-making and surgical technique of lumbar osteotomies for treatment of malalignment. A comprehensive literature review was performed on the history, indications, preoperative evaluation, and decision-making in patients with sagittal and coronal plane malalignment, as well as surgical technique for lumbar osteotomies. There has been an evolution of many different types of osteotomies for correcting deformities; however, three general categories exist: (1) posterior column osteotomy (PCO), (2) pedicle subtraction osteotomy (PSO), and (3) vertebral column resection (VCR). More recently, the Schwab classification describes six anatomically defined osteotomies that are commonly accepted and used. Utilizing the best available evidence, we review the indications and patient selection as a first step and then discuss the decision-making and preoperative planning. Lastly, we detail the surgical technique with emphasis on complication avoidance.

STUDY DESIGN: Case-matched retrospective. OBJECTIVES: The purpose of this study is to compare 2-year health-related quality of life (HRQOL) outcomes of patients who underwent 1-level or 2-level posterolateral spine fusion (PSF) versus transforaminal interbody fusion (TLIF) for degenerative spondylolisthesis, disk pathology, and postdecompression instability. SUMMARY OF BACKGROUND DATA: The optimal surgical technique for patients with spondylolisthesis or other degenerative conditions has not been defined. Historically, PSF was the most common procedure, whereas in recent years TLIF has gained popularity. Although theoretical advantages for TLIF have been outlined, evidence for improved outcomes with the addition of interbody support is limited. METHODS: Patients with degenerative spondylolisthesis, with disk pathology and or postdecompression instability who underwent 1-level or 2-level TLIF and completed 2 years postoperative HRQOL measures were identified from a prospective database. These patients were then propensity-matched to a cohort of PSF patients based on age, number of surgical levels, body mass index, sex, smoking status, workers' compensation status, and preoperative outcome measures including the Oswestry Disability Index, SF-36 Physical Component Summary score, SF-36 Mental Composite Summary score, and back and leg pain scores. This produced 63 matched pairs with degenerative spondylolisthesis, 46 with disk pathology and 32 with postdecompression instability. RESULTS: All patients in both groups for each cohort reported statistically significant improvement in HRQOL scores at 2 years postoperatively compared with baseline. Improvements in the Oswestry Disability Index, SF-36 Physical Component Summary score, and back and leg pain scores within the spondylolisthesis and disk pathology subgroups were similar between patients who had a TLIF compared with those who had a PSF. The postdecompression instability subgroup was the only subgroup in which TLIF outperformed PSF for every outcome measure. CONCLUSIONS: Clinical outcome was not significantly altered with TLIF as compared with PSF in patients with spondylolisthesis or disk pathology. However, TLIF resulted in better outcomes at 2 years postoperatively in patients with postdecompression instability.

BACKGROUND CONTEXT Surgeons have used lateral flexion–extension X-ray images to identify patients with clinically substantial instability and listhesis that require fusion. PURPOSE The purpose of this study is to determine the clinical utility of flexion–extension X-ray images by evaluating associations with supine MRI and lateral standing X-ray images and patient reported outcomes (PROs) at baseline and one-year post-op. STUDY DESIGN/SETTING Longitudinal cohort from a multisurgeon, single spine specialty practice. PATIENT SAMPLE Patients enrolled in quality outcome database from a single site with grade 1 spondylolisthesis. OUTCOME MEASURES Back pain (BP), leg pain (LP), and Oswestry Disability Index (ODI). METHODS Patients enrolled in QOD from a single site with grade 1 spondylolisthesis and complete preop and one-year postop PROs, including BP, LP, and ODI, and preop lumbar supine MRIs, lateral standing and flex–ext X-ray images were identified. Slip distance and percentage on all images were measured. Slip difference between flexion and extension was calculated. RESULTS Twenty-seven patients, mean age of 60.5years, 74% female were included. Mean listhesis on flexion films was significantly greater (8.5 mm) than on supine MRI (4.8 mm, p CONCLUSIONS There were no associations between preop or postop PROs and slip severity on any of the imaging modalities. As listhesis on standing and extension films were similar and slip difference between flexion and extension was not associated with PROs, lateral extension films may have limited clinical utility. Further studies are needed to clarify radiographic indications for fusion in patients with spondylolisthesis.

BACKGROUND CONTEXT Provisions in the Patient Protection and Affordable Care Act (PPAC) include alternative payment models that shift away from fee-for-service reimbursement and provide incentives to improve value. These reimbursement models could incorporate the post-discharge facility care and it is therefore important to identify drivers of additional cost, especially in the setting of unexpected non-home discharge. PURPOSE To identify factors associated with being discharged to a non-home location after an elective 1-2 level instrumented lumbar fusion that, if identified, can be useful to allow for early post-discharge planning. STUDY DESIGN/SETTING Retrospective chart review. PATIENT SAMPLE Patients undergoing 1-2 level instrumented lumbar fusions for degenerative lumbar conditions from 2016 to 2018. OUTCOME MEASURES Non-home discharge. METHODS Hospital administrative database and electronic medical record analysts identified consecutive patients undergoing 1-2 level instrumented lumbar fusions for degenerative lumbar conditions from 2016 to 2018. Discharge disposition was determined as home vs non-home (NH). A regression analysis was used to determine associations between NH discharge and an underserved zip code, ASA grade, marital status, race, insurance type, smoking status, BMI, number of levels, approach and revision surgery. RESULTS A total of 1,502 patients (601; 40% male) were included with a mean age of 57.5 years. The majority were discharged home (1,216; 81%). Of the 286 (19%) not discharged home, the majority went to a skilled nursing facility (248). Factors associated with a NH discharge were living in an underserved zip code, not being married, being on government insurance, having more levels fused, higher BMI and older age. Length of stay (5.64 vs 3.03 days, p CONCLUSIONS Patients living in an underserved zip code, not married, higher BMI, older, and having government insurance are more likely to be discharged to a non-home facility after undergoing 1-2 instrumented lumbar fusions. Identification and early intervention to place these patients even before admission may decrease the length of hospital stay and cost. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT In the future, payers may not cover unplanned 90-day emergency room (ER) visits or readmissions after elective lumbar spine surgery. Prior studies using large administrative databases lack granularity, and/or use a proxy for actual cost. We analyzed a large, single-center database to identify risk factors and subsequent costs associated with 90-day ER visits and readmissions. PURPOSE To identify risk factors and subsequent costs associated with 90-day ER visits and readmissions. STUDY DESIGN/SETTING Retrospective longitudinal cohort from a single multisurgeon, spine specialty site PATIENT SAMPLE Patients undergoing elective lumbar spine surgeries from 2013-2017. OUTCOME MEASURES Ninety-day ER visits and readmissions. METHODS A prospective, multisurgeon, single-center database merged with hospital administrative data was queried for elective lumbar spine surgeries from 2013-2017. Predictive models were created for 90-day ER visits and readmissions. RESULTS Of 5,444 patients, 729 (13%) returned to the ER, most often for pain (144, 32%). Predictors of an ER visit were prior ER visit (pER, OR:2.4), zip code (OR:1.4) and number of chronic medical conditions (OR:1.4). 421 (8%) patients were readmitted, most frequently for wound infection (123, 2%), COPD exacerbation (24, 0.4%), and sepsis (23, 0.4%). Predictors for readmission were pER (OR:1.96), multiple chronic conditions (OR:1.69), obesity (non-obese, OR:0.49), race (African American, OR:1.43), admission status (ER admission, OR:2.29) and elevated HbA1c (OR:1.80). Average direct hospital cost for an ER visit was $1,659 and readmission was $7,322, costing the institution $5.1 million over the five-year study period. CONCLUSIONS Risk factors for 90-day ER visit and readmission after elective lumbar spine surgery include medical comorbidities and socioeconomic factors. Proper patient selection, appropriate postop pain management and optimization of modifiable risk factors prior to surgery can lower the 90-day ER visits and readmissions and reduce health care costs. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Objective Posterior interbody fusion is commonly performed for degenerative lumbar conditions. A minimally invasive technique of midline exposure limited only to the facets and fixation with laterally directed cortical bone trajectory (CBT) screws was introduced with the intent of decreasing surgical morbidity. The purpose of this study was to determine if posterior interbody fusion with this limited midline exposure will have less blood loss and shorter operative times (i.e., can be considered minimally invasive) compared to traditional open transforaminal interbody fusion. Methods A consecutive single-surgeon series of patients who underwent posterior interbody fusion with either a navigated, midline only exposure (MidLIF) or full, traditional open, exposure of the transverse processes with a posterolateral fusion (open TLIF) were identified. Demographic, peri-operative data, patient reported outcomes (PROs), and reoperation/readmission rates were collected and compared. Results There were 29 cases in the MidLIF and 27 in the open TLIF group. Both groups were similar with respect to surgical indications, age, BMI, gender, ASA grade and operative level. The MidLIF group had significantly lower estimated blood loss (266 vs. 446 cc, p = 0.003), shorter operative time (170 vs. 210 minutes, p = 0.003), and shorter length of hospital stay (2.9 vs. 3.7 days, p = 0.016) compared to the open TLIF group. A sub-analysis of single-level cases showed similar findings with significantly lower estimated blood loss (247 vs. 411 cc, p = 0.10), shorter operative time (159 vs. 199 min, p = 0.003), and shorter length of hospital stay (2.9 vs. 3.7 days, p = 0.023) in the MidLIF group. Patient reported outcomes at 6 weeks, 3 months, 6 months, 12 months and 24 months post-operative favored MidLIF with significantly greater ODI improvements at both 6 weeks and 12 months; and lower ODI and back pain at both 12 months and 24 months. Conclusions MidLIF had lower blood loss and shorter operative time compared to the traditional open TLIF technique. These differences compare well to reported values in the literature for tubular minimally-invasive TLIF. Patient reported outcomes from 6 weeks to 24 months post-operative, hospital length of stay, and reoperation/readmission rates all favored MidLIF compared to traditional open TLIF.

BACKGROUND CONTEXT Our previous study showed that prescribing patterns, more than surgery invasiveness or patient factors, affect post-operative opioid consumption. Since then we have instituted a Standard Escalation Pain Protocol (SEPP): patients receive 0-60 Morphine Milligram Equivalents (MME) above their baseline pre-op MME after surgery. PURPOSE The purpose of this study is to evaluate how prescribing patterns affect immediate postoperative opioid consumption in patients undergoing 1- to 2-level posterior lumbar interbody fusion with a navigated or robotic-assisted, midline exposure (MIDLIF). STUDY DESIGN/SETTING Single surgeon consecutive series. PATIENT SAMPLE Patients with degenerative lumbar pathology who had a MIDLIF from 2017 to 2018 were identified. OUTCOME MEASURES In-hospital opioid consumption. METHODS Patients with degenerative lumbar pathology who had a MIDLIF from 2017 to 2018 were identified and divided into two cohorts: patients who had surgery before the institution of SEPP (PreSEPP) and those who had surgery after (PostSEPP). Length of stay and daily opioid consumption were extracted by EMR data analysts unaware of the purpose of the study. RESULTS The PreSEPP (N=34) and PostSEPP (N=27) patients were similar at baseline in age, sex distribution, ASA grade, BMI and smoking status. Pre-Op (2.2 vs 3.6, p=0.630) and Post-op Day-0 (POD-0, 52.5 vs 38.8, p=0.192) MME consumption was similar between the two groups. At POD-1, cumulative MME consumption was higher in the Pre-SEPP (131.7) compared to the PostSEPP group (76.0, p=0.004) and this was maintained up to discharge (54% total MME reduction). Length of stay was also longer in the PreSEPP (1.97 days) compared to the PostSEPP group (1.37 days, p=0.004). CONCLUSIONS The use of a standard escalation pain protocol decreases in-hospital opioid consumption by 54% and shortens length of stay after 1-2 level lumbar spinal fusion. Similar to our previous study, prescribing pattern is an important factor affecting post-op opioid consumption. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Object Recent studies have reported the incidence of superior facet joint violation using percutaneous techniques. These techniques have not been compared with the open midline approach. An increased incidence of superior facet violation may lead to adjacent-segment disease. In this paper, the authors' goal is to compare the rate of superior facet violation with the use of percutaneously placed pedicle screws versus midline approach open placement. Methods Patients who underwent a single-level fusion using a percutaneous approach from L-1 to S-1 who had undergone CT scanning within 1 year after surgery were identified. A cohort who underwent open fusion matched by level of surgery was identified. All CT scans were reviewed by 3 fellowship-trained spine surgeons to determine the degree of facet violation. The final categorization for each screw was based on the most frequent reading among the 6 evaluations. The Fisher test was used to determine the association of facet violation with approach. Results There were 66 patients in each group. Patients in the Percutaneous group were younger (mean 42.5 years) than those in the Open group (mean 57.8 years, p = 0.000). There was no statistically significant difference in sex distribution, surgical levels fused, or time between surgery and CT scan between the groups. Thirty-six (13.6%) of 264 screws in the percutaneous and 16 (6%) of 263 screws in the Open group were in the facet joint (p = 0.005). Of these, 17 (12%) of the 132 proximal screws in the percutaneous and 7 (5%) of the 131 proximal screws in the Open group were in the facet joint (p = 0.052). Conclusions The use of a percutaneous method to insert pedicle screws results in a statistically significantly higher incidence of facet joint violation, even if only proximal screws are considered. Further studies are needed to determine if this leads to a higher incidence of symptomatic adjacent-level disease.

Study design: Retrospective review. Objective: To identify risk factors for cell saver transfusion in lumbar spinal surgery and determine if cell saver transfusions affected intraoperative or postoperative transfusion rates. Summary of background data: Cell saver has been used to minimize allogeneic blood transfusion in lumbar spinal surgery. Conflicting reports exist, which call into question the efficacy of cell saver use. Methods: We reviewed medical records of randomly selected patients who underwent posterolateral fusion with or without transforaminal interbody fusion from July 2010 to June 2011. Transfusion rates and transfusion-related complications were determined. Binary logistic regression was performed to identify risk factors for use of autologous cell saver transfusion. Results: There were 178 females and 107 males, with a mean age of 57.2 years. Of the 285 cases, 39 had no cell saver available, 147 had cell saver available but no autologous blood was recovered or transfused and 99 had an autologous cell saver transfusion. Patients who had cell saver transfusion had a higher rate of intraoperative allogeneic blood transfusion (52%) compared with those who did not (22%). There was no significant difference in the rate of postoperative transfusions or transfusion-related reactions between patients who did and did not have cell saver transfusion. Patient's age, smoking status, American Society of Anesthesiologists grade, use of anticoagulants preoperatively, primary or revision surgery, iliac crest bone graft harvest, anesthesiologist, or surgeon had no significant effect on cell saver infusion. Body mass index (odds ratio [OR] = 1.06), number of posterolateral fusion levels fused (OR = 2.50), and number of transforaminal interbody fusions performed (OR = 2.41) were independent risk factors for the use of autologous cell saver transfusion. Conclusion: Body mass index, multi-level fusion and transforaminal interbody fusion result in increased use of autologous cell saver transfusion in lumbar spinal surgery. Use of autologous cell saver transfusion did not reduce the requirement for intraoperative or postoperative allogeneic blood transfusion. Level of evidence: 2.

Object Previous studies have reported on the minimum clinically important difference (MCID), a threshold of improvement that is clinically relevant for lumbar degenerative disorders. Recent studies have shown that pre- and postoperative health-related quality of life (HRQOL) measures vary among patients with different diagnostic etiologies. There is also concern that a patient's previous care experience may affect his or her perception of clinical improvement. This study determined if MCID values for the Oswestry Disability Index (ODI), 36-Item Short-Form Health Survey (SF-36), and back and leg pain are different between patients undergoing primary or revision lumbar fusion. Methods Prospectively collected preoperative and 1-year postoperative patient-reported HRQOLs, including the ODI, SF-36 physical component summary (PCS), and numeric rating scales (0–10) for back and leg pain, in patients undergoing lumbar spine fusion were analyzed. Patients were grouped into either the primary surgery or revision group. As the most widely accepted MCID values were calculated from the minimum detectable change, this method was used to determine the MCID. Results A total of 722 patients underwent primary procedures and 333 patients underwent revisions. There was no statistically significant difference in demographics between the groups. Each group had a statistically significant improvement at 1 year postoperatively compared with baseline. The minimum detectable change–derived MCID values for the primary group were 1.16 for back pain, 1.36 for leg pain, 12.40 for ODI, and 5.21 for SF-36 PCS. The MCID values for the revision group were 1.21 for back pain, 1.28 for leg pain, 11.79 for ODI, and 4.90 for SF-36 PCS. These values are very similar to those previously reported in the literature. Conclusions The MCID values were similar for the revision and primary lumbar fusion groups, even when subgroup analysis was done for different diagnostic etiologies, simplifying interpretation of clinical improvement. The results of this study further validate the use of patient-reported HRQOLs to measure clinical effectiveness, as a patient's previous experience with care does not seem to substantially alter an individual's perception of clinical improvement.

OBJECTIVE Studies have shown that anxious or depressed patients may have poorer outcomes after lumbar fusion. These conclusions were drawn from questionnaires specifically designed to measure anxiety and depression. The objective of this study is to determine if responses to the EQ-5D anxiety/depression domain or the items used to calculate the 36-Item Short-Form Health Survey (SF-36) Mental Component Summary (MCS) can predict outcomes after lumbar fusion surgery. METHODS Patients enrolled in the National Neurosurgery Quality and Outcomes Database from a single center with 1-year follow-up were identified. The outcomes collected include the Oswestry Disability Index (ODI), EQ-5D, SF-36, and the back- and leg-pain numeric rating scales (range 0–10). Linear regression modeling was performed to predict the 1-year ODI scores using the EQ-5D anxiety/depression domain and the 14 items used to calculate SF-36 MCS. RESULTS Complete data were available for 312 (88%) of 353 eligible patients. The mean patient age was 58.5 years, 175 (56%) patients were women, and 52 patients were smokers. After controlling for other factors, the item in the SF-36 that asks “Have you felt downhearted and depressed?” is the strongest predictor of the 1-year ODI score (r2 = 0.191; p = 0.000) and 1-year EQ-5D score (r2 = 0.205; p = 0.000). Neither the EQ-5D anxiety/depression domain nor the diagnoses of anxiety or depression were predictors of 1-year outcomes. CONCLUSIONS Patient responses to SF-36 item “Have you felt downhearted and depressed?” account for 20% of the variability of the 1-year ODI and EQ-5D scores and can be used by clinicians to screen for anxiety or depression in patients prior to lumbar fusion surgery. Clinicians may offer psychological support to these patients preoperatively in order to improve treatment outcomes.

In this study, we compare intermediate-term outcomes in minimally invasive surgical transforaminal lumbar interbody fusion (MIS TLIF) to open TLIF. Sixty-four patients who underwent 1- to 2-level MIS TLIF with baseline, 1-, and 2-year outcome measures were identified. These were propensity-matched to a cohort of open TLIF patients based on age, body mass index, sex, smoking status, workers' compensation status, and preoperative outcome measures. At 1 year, both groups had similar improvements in pain and Short-Form 36 (SF-36) Physical Composite Summary (PCS), but the MIS TLIF group had a statistically significantly greater improvement in Oswestry Disability Index (ODI) compared with the open TLIF group. At 2 years, the MIS TLIF group had a statistically significantly greater improvement in pain and ODI compared with the open TLIF group, but no statistically significant difference in SF-36 PCS. Both MIS TLIF and open TLIF lead to significant improvements in clinical outcomes. At 1 year after surgery, MIS TLIF patients had greater improvements in ODI, and at 2 years after surgery, they had greater improvements in pain and ODI. This study showed that the perioperative advantages of MIS TLIF, such as less muscle dissection and faster recovery, continue to be beneficial 1 to 2 years after surgery.

Object Clinical studies use both disease-specific and generic health outcomes measures. Disease-specific measures focus on health domains most relevant to the clinical population, while generic measures assess overall health-related quality of life. There is little information about which domains of the Oswestry Disability Index (ODI) are most important in determining improvement in overall health-related quality of life, as measured by the 36-Item Short Form Health Survey (SF-36), after lumbar spinal fusion. The objective of the study is to determine which clinical elements assessed by the ODI most influence improvement of overall health-related quality of life. Methods A single tertiary spine center database was used to identify patients undergoing lumbar fusion for standard degenerative indications. Patients with complete preoperative and 2-year outcomes measures were included. Pearson correlation was used to assess the relationship between improvement in each item of the ODI with improvement in the SF-36 physical component summary (PCS) score, as well as achievement of the SF-36 PCS minimum clinically important difference (MCID). Multivariate regression modeling was used to examine which items of the ODI best predicted achievement for the SF-36 PCS MCID. The effect size and standardized response mean were calculated for each of the items of the ODI. Results A total of 1104 patients met inclusion criteria (674 female and 430 male patients). The mean age at surgery was 57 years. All items of the ODI showed significant correlations with the change in SF-36 PCS score and achievement of MCID for the SF-36 PCS, but only pain intensity, walking, and social life had r values > 0.4 reflecting moderate correlation. These 3 variables were also the dimensions that were independent predictors of the SF-36 PCS, and they were the only dimensions that had effect sizes and standardized response means that were moderate to large. Conclusions Of the health dimensions measured by the ODI, pain intensity, walking, and social life best predicted improvement in overall health-related quality of life, as measured using the SF-36 PCS.

Background context Acinic cell carcinoma is the fourth most common tumor of the parotid gland, and spinal metastases are thought to be exceedingly rare. Only two other reported presentations are found in the literature, both presumably secondary to incomplete surgical resections. Purpose To present the first known case of metastasis to the lumbar spine causing vertebral body involvement, after complete resection of the parotid gland. Study design Case report. Methods A case of a patient who presented with low back pain and had imaging studies showing an expansive destructive lesion of the L4 vertebral body. The patient underwent a radical parotidectomy and radiation therapy for dedifferentiated, high-grade acinic cell carcinoma 2 years prior. Results The patient underwent anterior L4 corpectomy and strut cage placement and posterior pedicle screw fixation from L2 to L5 on the same day, followed by radiation and oral chemotherapy 3 weeks later. Histopathologic examination confirmed metastatic dedifferentiated acinic cell carcinoma, present in the L4 vertebral body and overlying psoas muscle. Conclusions This case report underscores the importance of careful evaluation of patients presenting with back pain with a history of malignancy. It also calls into question the traditional low-grade classification ascribed to these tumors, given their ability to metastasize after complete excision and adjuvant therapy.

BACKGROUND CONTEXT In 2016 alone, 19,413 deaths were attributed to prescription opioid overdoses. Understanding the drivers of opiate consumption in postoperative lumbar spinal fusion patients is a high priority. PURPOSE To determine if surgical invasiveness and/or preoperative opiate use influences immediate postoperative opiate consumption. STUDY DESIGN/SETTING Propensity matched longitudinal cohort. PATIENT SAMPLE Patients from a multi-surgeon, single spine specialty center with degenerative lumbar pathology who underwent an instrumented posterior lumbar decompression and interbody fusion (MIDLIF or TLIF). OUTCOME MEASURES Oswestry Disability Index, morphine equivalent doses (MED) from postoperative day (POD) #0 through POD #4. METHODS A single-center, multi-surgeon, retrospective review identified patients with degenerative lumbar pathology who underwent an instrumented posterior lumbar decompression and interbody fusion (MIDLIF or TLIF). Patients in each cohort were propensity-matched based on age, sex, smoking status, BMI, diagnosis, ASA grade and levels fused. MED POD #0 through POD #4 were calculated. Preoperative opiate prescriptions were recorded to determine baseline opioid use. RESULTS Of 214 MIDLIF and 281 TLIF patients undergoing surgery, 33 patients in each cohort were successfully propensity matched with no differences in baseline characteristics. There was no difference in immediate postoperative mean total MED between the cohorts (MIDLIF=370, TLIF=302, p=.398). Forty-three (65%) of patients were taking opiates prior to surgery. Opiate-naive patients required less narcotics (MED=248) compared to nonopiate naive patients (MED=383, p=.071) but this was not significant. Patients taking opiates preop had worse baseline ODI (56.5 vs. 47.2, p=.023) and 1-year postop ODI (46.3 vs. 30.9, p=.015). CONCLUSIONS Neither surgical invasiveness nor preoperative opiate use have an impact on immediate postop opiate consumption. This is likely secondary to non-individualized prescribing patterns. Patients taking preop narcotics have worse baseline, 1-year, and improvement in ODI following 1- and 2-level MIDLIFs or TLIFs. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Posterior instrumented lumbar fusions are commonly performed utilizing interbody fusions. Recently, a minimally invasive technique of midline exposure with cortical bone trajectory screw fixation has been described (MIDLIF). The goal is to limit muscle dissection, decreasing surgical morbidity and expedite recovery. PURPOSE The purpose of this study was to compare index episode of care (iEOC) cost between patients undergoing MIDLIF versus tTLIF. STUDY DESIGN/SETTING Multi-surgeon single-center spine specialty tertiary practice. PATIENT SAMPLE Consecutive patients undergoing 1- or 2-level MIDLIF or tTLIF for degenerative lumbar conditions were identified. OUTCOME MEASURES Index episode of care cost data for surgical and hospital stay parameters and included actual, direct, hospital cost. METHODS A retrospective review of a prospective, multi-surgeon, surgical database was utilized. Consecutive patients undergoing 1- or 2-level MIDLIF or tTLIF for degenerative lumbar conditions were identified. Patients in each cohort were propensity-matched based on age, sex, smoking status, BMI, diagnosis, ASA grade and levels fused. iEOC cost data was collected for surgical and hospital stay parameters and included actual, direct, hospital cost for the index surgical visit. RESULTS Of 214 and 281 patients undergoing MIDLIF or tTLIF, respectively, 105 cases in each cohort were successfully propensity-matched. Consistent with propensity matching, there was no difference in age, sex, BMI, diagnosis, ASA score, smoking status, or levels fused. Spondylolisthesis was the most common indication for surgery in both cohorts. The mean total iEOC was $706 ($16,604 vs. $17,310) lower for MIDLIF versus tTLIF. There was no difference in implant (p=.193) or biologic (p=.145) cost but blood utilization (p=.000), OR supplies (p=.000), hospital room/board (p=.000), pharmacy (p=.010), and therapy (p=.009) costs were all significantly lower in MIDLIF. Additionally, mean LOS was decreased for MIDLIF (2.97 vs. 4.02, p=.000). CONCLUSIONS Compared to traditional open tTLIF, patients undergoing MIDLIF have several cost parameters of the iEOC that are significantly lower as well as a shorter length of stay. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Study design Randomized clinical trial. Objective To perform a cost-utility analysis using actual cost data from a randomized clinical trial of patients over 60 years old who underwent posterolateral fusion using either rhBMP-2/ACS or iliac crest bone graft (ICBG). Summary background data Bone morphogenetic protein has been shown to be an effective bone graft substitute for spine fusion. However, a clinical trial-based economic analysis of rhBMP-2/ACS compared with iliac crest bone graft has not been done. Methods Patients over 60 years old requiring decompression and posterolateral fusion were randomized to rhBMP-2/ACS (n = 50) or ICBG (n = 52). A dedicated hospital coder and research nurse tracked each patient to determine direct costs of inpatient care and all postoperative healthcare encounters up to 2 years after surgery. Preoperative and 2-year-postoperative SF-6D utility scores for each patient were determined. A decision tree was created, which included the probability of complications, need for additional treatments and revision surgery; and the costs associated with initial surgery and treatment for complications and additional treatment for continued spine symptoms; and utility scores. Results The mean total 2-year cost for care (excluding complication and additional spine treatment costs) was $34,235 in the ICBG group and $36,530 in the rhBMP-2/ACS group. For the entire group, the mean cost to treat a major complication was $10,888, the cost of revision surgery for nonunion was $46,852, and additional treatment for spine-related events was $5892. In the ICBG group, 8 patients had complications; 20 had additional interventions, 5 of whom required revision for nonunion. In the rhBMP-2/ACS group, 6 patients had complications, 10 had additional interventions, and 1 required revision for nonunion. The cost of using rhBMP-2/ACS was $39,967 with a 0.11 mean improvement in SF-6D; and for ICBG the cost was $42,286 with a mean improvement of 0.10 in SF-6D. Conclusion There are more complications, increased need for additional treatment and revision surgery in patients over 60 years old receiving ICBG compared with rhBMP-2/ACS. This may account for higher costs and lower improvements in utility seen in patients receiving ICBG compared with rhBMP-2/ACS in this study population.

Background One of the primary difficulties in evaluating the effectiveness of lumbar fusion is that, with the exception of spondylolisthesis, specific diagnostic indications for surgery are poorly defined. Diagnostic specificity beyond the symptom of low back pain or the presence of lumbar degeneration needs to be delineated such that outcomes data can be effectively translated into clinical decision making or evidence-based guidelines. Purpose The purpose of this study was to report on prospectively collected clinical outcome measures, stratified by diagnosis, among a series of patients with lumbar degenerative disease whose treatment included lumbar spine fusion. Study design Demographics, diagnostic categorization, and clinical outcome measures were prospectively collected by six spine surgeons at a single tertiary spine center, as part of the surgeons' standard clinical practice. Patient sample Four hundred and twenty-eight patients were enrolled in the study and complete 1- and 2-year Health-Related Quality of Life (HRQOL) data were available in 327 patients whose treatment included decompression and posterolateral lumbar fusion. Outcome measures The Oswestry Disability Index (ODI), Short Form-36 (SF-36), numeric rating scales for back pain and leg pain. Methods Preoperative diagnosis was classified, in the primary surgical cases, as disc pathology, spondylolisthesis, instability, stenosis, or scoliosis. In revision cases, the diagnosis was classified as nonunion, adjacent level degeneration, or postdiscectomy revision. Patient-reported outcomes at 1 and 2 years post-op were assessed based on diagnostic stratification. Statistical evaluation of clinical outcome was performed for both mean net change in outcome scores and the percentage of patients reaching a minimum clinically important difference (MCID) threshold for each outcome measure. Results Preoperative diagnosis was spondylolisthesis (n=80), scoliosis (n=17), disc pathology (n=33), instability (n=21), stenosis (n=46), postdiscectomy revision (n=67), adjacent level degeneration (n=40), or nonunion (n=23). Evaluation of 2-year post-op HRQOL measures by diagnostic subgroup revealed the most substantial improvement in ODI score for patients with spondylolisthesis (22.7 points) and scoliosis (21.2 points). Patients with the diagnosis of disc pathology (16.2 points), postdiscectomy revision (14.0 points), instability (12.7 points), stenosis (10.6 points), and adjacent level degeneration (9.5 points) demonstrated a progressively smaller magnitude of ODI improvement. The least ODI improvement at 2 years after surgery was seen in patients with nonunion of a prior fusion (5.5 points). The percentage of patients reaching MCID for ODI at 2 years post-op ranged from 71.0% in the spondylolisthesis subgroup to 34.8% in the nonunion subgroup. The greatest SF-36 physical component score improvement at 2-year follow-up was seen in patients with disc pathology (7.9 points) and spondylolisthesis (7.7 points), followed by scoliosis (6.6 points) and stenosis (6.5 points), instability (5.6 points), postdiscectomy revision (5.3 points) nonunion (3.1 points) and adjacent level degeneration (2.5 points). No significant changes from Year 1 to Year 2 were noted in any of the subgroups. For SF-36 physical component score, percentage of patients reaching MCID ranged from 63.6% in the disc pathology subgroup to 25% in the nonunion subgroup. Conclusions This study supports the concept that added diagnostic specificity is a critical component in building an improved evidence base for lumbar fusion surgery. The magnitude of HRQOL improvement was not equal among diagnostic subgroups. The percentage of patients reaching an MCID level of improvement was also significantly influenced by diagnostic stratification. Without diagnostic specificity for entities beyond spondylolisthesis, the absence of well-defined study populations will continue to limit our ability to move toward evidence-based decision making.

Sagittal imbalance is a significant factor in determining clinical treatment outcomes in patients with deformity. Measurement of sagittal alignment using the traditional Cobb technique is frequently hampered by difficulty in visualizing landmarks. This report compares traditional manual measurement techniques to a computer-assisted sagittal plane measurement program which uses a radius arc methodology. The intra and inter-observer reliability of the computer program has been shown to be 0.92–0.99. Twenty-nine lateral 90 cm radiographs were measured by a computer program for an array of sagittal plane measurements. Ten experienced orthopedic spine surgeons manually measured the same parameters twice, at least 48 h apart, using a digital caliper and a standardized radiographic manual. Intraclass correlations were used to determine intra- and interobserver reliability between different manual measures and between manual measures and computer assisted-measures. The inter-observer reliability between manual measures was poor, ranging from −0.02 to 0.64 for the different sagittal measures. The intra-observer reliability in manual measures was better ranging from 0.40 to 0.93. Comparing manual to computer-assisted measures, the ICC ranged from 0.07 to 0.75. Surgeons agreed more often with each other than with the machine when measuring the lumbar curve, the thoracic curve, and the spino-sacral angle. The reliability of the computer program is significantly higher for all measures except for lumbar lordosis. A computer-assisted program produces a reliable measurement of the sagittal profile of the spine by eliminating the need for distinctly visible endplates. The use of a radial arc methodology allows for infinite data points to be used along the spine to determine sagittal measurements. The integration of this technique with digital radiography’s ability to adjust image contrast and brightness will enable the superior identification of key anatomical parameters normally not available for measurement on traditional radiographs, improving the consistency of sagittal measurement.

STUDY DESIGN Retrospective cohort analysis. OBJECTIVE To investigate and compare back and leg pain, and health-related quality of life measures in obese patients undergoing lumbar spine fusion, and to compare the results to nonobese patients. SUMMARY OF BACKGROUND DATA Obesity is a growing healthcare crisis in the United States and an increasing number of patients undergoing spinal surgery are obese. Obesity is also associated with low back pain. Some obese patients with significant structural spine problems may be dismissed as having their pain only coming from their weight. We compared patient outcomes in obese and nonobese patients undergoing lumbar fusion surgery. METHODS We retrospectively reviewed a single-center patient database of patients undergoing lumbar fusion and identified 270 patients with greater than 2-year outcome data. Body mass index (BMI) was calculated and patients were classified as obese (BMI >or= 30) or nonobese (BMI < 30). All patients completed Oswestry Disability Index (ODI), Short Form (SF)-36 questionnaires, and back and leg pain numerical rating scores before surgery and at 2 years. We compared clinical outcomes and complication rates in the 2 groups. RESULTS The overall study group consisted of 109 obese patients and 161 nonobese patients. Both the obese and nonobese patients demonstrated significant improvements in back pain, leg pain, SF-36 physical composite summary (PCS), and ODI scores (P < 0.001) at 2-year follow-up compared with baseline. There was no significant difference in the mean improvements seen in obese patients compared with nonobese patients with respect to back pain, leg pain, or SF-36 PCS or ODI scores. Both SF-36 PCS (P = 0.037) and ODI score (P = 0.028) at 2-year follow-up were better in the nonobese patients compared with the obese patients. Overall complication rates were slightly higher in the obese group (P = 0.045), predominantly because of wound-related complications. CONCLUSION Obese patients undergoing lumbar fusion achieve similar benefits to nonobese patients. Wound-related complications are more common in obese patients. Obese patients with otherwise good indications for lumbar fusion should not be denied this procedure because of their weight.

Background context There is mounting evidence supporting the efficacy of bone morphogenetic protein (BMP) for both anterior interbody and posterolateral lumbar fusion. However, the relative cost of BMP remains an important concern for physicians, hospitals, and payers. Purpose The purpose of this study is to report on the perioperative costs for patients treated with rhBMP-2 as compared with an iliac crest bone graft (ICBG) supplemented with graft extenders. Study design/setting A prospective randomized controlled trial of rhBMP-2/ACS (Infuse Bone Graft; Medtronic Sofamor Danek, Memphis, TN) versus ICBG±graft extender for lumbar spine fusion in patients over 60 years old. Patient sample One hundred two patients over 60 years old who required a posterolateral lumbar spine fusion randomized between receiving rhBMP-2/ACS or ICBG. Outcome measures All health-care costs over the first 3 months after surgery. Methods As part of a prospective randomized trial of rhBMP-2/ACS versus ICBG±graft extender for lumbar spine fusion, all costs over the first 3 months after surgery were directly recorded by a dedicated coder funded by Norton Healthcare, Louisville, KY. A dedicated research nurse also followed all patients throughout their hospital stay and posthospitalization recovery to identify any adverse events or additional outpatient medical care. Results Fifty patients received rhBMP-2/ACS and 52 underwent ICBG harvest. The mean hospital cost for the index admission was $24,736 for the rhBMP-2/ACS group and $21,138 for the ICBG group. Mean inpatient physician costs were $5,082 in the rhBMP-2/ACS group and $5,316 in the ICBG group. Costs associated with posthospital rehabilitation averaged $4,906 in the rhBMP-2/ACS group versus $6,820 in the ICBG group. Total payer expenditure for the 3-month perioperative period averaged $33,860 in the rhBMP-2/ACS group and $37,227 in the ICBG group. Conclusions The hospital carries the cost burden associated with the utilization of rhBMP-2/ACS. In contrast, the payer in a Diagnosis-Related Group (DRG) model achieves a net savings, based primarily on the decreased payment for inpatient rehabilitation, but also on decreased hospital reimbursement, physician costs, and other outpatient services.

Although outcomes after cervical fusion in rheumatoid arthritis (RA) patients are widely published, outcomes of lumbar fusion in RA patients has not been reported. Nineteen patients with RA, identified using ICD-9 and CPT codes, who underwent instrumented posterolateral lumbar fusion were matched for age, gender, smoking status, date, and level of surgery to a contemporaneous non-RA group. Medical records and radiographs were reviewed by the primary author who had no role in the treatment of these patients. The average age was 64 years in the RA group and 65 years in the non-RA group. The male to female ratio was 2:17 and 1:18, respectively. There were three smokers and two diabetics in each group. An average of 1.5 levels was fused in each group. Average follow-up was 24 and 27 months, respectively. In the RA group, 15 patients were taking DMARDs with 7 of those also taking oral steroids; 4 patients were taking NSAIDs only. There were seven complications (37%) in the RA group versus four (21%) in the non-RA group; wound infections in three patients (16%) in the RA group versus one (5%) in the non-RA group; and non-union in two patients (11%) in the RA group versus three (16%) in the non-RA group. Clinical outcomes were similar between the two groups with 74% of patients achieving good to excellent results in the RA group compared to 63% in the non-RA group (p = 0.692). Surgeons and their RA patients who undergo an instrumented lumbar fusion can expect a slightly higher complication rate than patients without RA which may be related to osteopenia and immunosuppression.