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There is limited research regarding the association between the mFI-5 and postoperative complications among adult spinal deformity (ASD) patients.Using the National Surgical Quality Improvement Project (NSQIP) database, patients with Current Procedural Terminology (CPT) codes for 7-level fusion or 7-level fusion with International Classification of Diseases, Ninth Revision (ICD-9) codes for ASD were identified between 2008 and 2016. Univariate analyses with post-hoc Bonferroni correction for demographics and preoperative factors were performed. Logistic regression assessed associations between mFI-5 scores and 30-day post-operative outcomes.2,120 patients met criteria. Patients with an mFI-5 score of 4 or 5 were excluded, given there were20 patients with those scores. Patients with mFI-5 scores of 1 and 2 had increased 30-day rates of pneumonia (3.5 % and 4.3 % vs 1.6 %), unplanned postoperative ventilation for 48 h (3.1 % and 4.3 % vs 0.9 %), and UTIs (4.4 % and 7.4 % vs 2.0 %) than patients with a score of 0 (all, p 0.05). Logistic regression revealed that compared to an mFI-5 of 0, a score of 1 was an independent predictor of 30-day reoperations (OR = 1.4; 95 % CI 1.1-18). A score of 2 was an independent predictor of overall (OR = 2.4; 95 % CI 1.4-4.1) and related (OR = 2.2; 95 % CI 1.2-4.1) 30-day readmissions. A score of 3 was not predictive of any adverse outcome.The mFI-5 score predicted complications and postoperative events in the ASD population. The mFI-5 may effectively predict 30-day readmissions. Further research is needed to identify the benefits and predictive value of mFI-5 as a risk assessment tool.

Background: Upper extremity (UE) microsurgical reconstruction relies upon proper wound healing for optimal outcomes. Cigarette smoking is associated with wound healing complications, yet conclusions vary regarding impact on microsurgical outcomes (replantation, revascularization, and free tissue transfer). We investigated how smoking impacted 30-day standardized postoperative outcomes following UE microsurgical reconstruction. Methods: Utilizing the National Surgical Quality Improvement Program, all patients who underwent (1) UE free flap transfer (n = 70) and (2) replantation/revascularization (n = 270) were identified. For each procedure, patients were stratified by recent smoking history (current smoker ≤1-year preoperatively). Baseline demographics and standardized 30-day complications, reoperations, and readmissions were compared between smokers and nonsmokers. Results: Replantation/revascularization patients had no differences in sex, race, or body mass index between smokers (n = 77) and nonsmokers. Smokers had a higher prevalence of congestive heart failure (5.2% vs 1.0%, P = .036) and nonsmokers were more often on hemodialysis (15.6% vs 10.4%, P = .030). Free flap transfer patients had no differences in age, sex, or race between smokers (n = 14) and nonsmokers. Smokers had a longer length of stay (6.6 vs 4.2 days, P = .001) and a greater prevalence of chronic obstructive pulmonary disorder (COPD; 7.1% vs 0%, P = .044). Recent smoking was not associated with increased odds of any 30-day minor and major standardized surgical complications, readmissions, or reoperations following UE microsurgical reconstruction via free flap transfer or replantation/revascularization. Baseline diagnosis of COPD was also not a predictor of adverse 30-day outcomes following free flap transfer. Conclusion: Recent smoking history was not associated with any 30-day adverse outcomes following UE microsurgical reconstruction via replantation/revascularization or free flap transfer. In light of these findings, further investigation is warranted, with particular focus on adverse events specific to free flaps and replantation/revascularization.

Retrospective cohort study.The objective of this study was to examine associations of gabapentin use with inpatient postoperative daily pain scores and opioid use in children undergoing PSF for AIS.Gabapentin use in posterior spinal fusion (PSF) postoperative pain management for adolescent idiopathic scoliosis (AIS) is increasingly common in order to decrease opioid use and improve pain control, though there is conflicting data on dosing and effectiveness to support this practice in real world settings.Retrospective cohort study of children aged 10 to 21 years undergoing PSF for AIS between January 2013 and June 2016 at an urban academic tertiary care center. Adjuvant gabapentin exposure was defined as at least 15 mg/kg/d by postoperative day (POD) 1 with an initial loading dose of 10 mg/kg on day of surgery. Primary outcomes were daily postoperative mean pain score and opioid use [morphine milligram equivalents/kg/day(mme/kg/d)]. Secondary outcomes were short and long-term complications.Among 129 subjects (mean age, 14.6 y, 74% female, mean coronal cobb, 55.2 degrees), 24 (19%) received gabapentin. Unadjusted GABA exposure was associated with significantly lower opioid use on POD1 and 2 (49% and 31%mme/kg/d, respectively) and lower pain scores (14%) on POD2. Adjusting for preexisting back pain, preoperative coronal Cobb angle, and site, GABA use was associated with significantly lower mean pain scores on POD1 through POD3 (-0.68, P=0.01; -0.86, P=0.002; -0.63, P=0.04). Gabapentin use was also associated with decreased opioid use on POD1 and POD2 (-0.39mme/kg/d, P0.001; -0.27, P=0.02). There was no difference in complications by gabapentin exposure.Addition of gabapentin as adjuvant therapy for adolescent PSF, beginning on day of surgery, is associated with improved pain scores and decreased opioid use in the first 48 to 72 hours postoperatively.This is a retrospective cohort study, classified as Level III under "Therapeutic Studies Investigating the Results of a Treatment."

Background: Klippel–Feil syndrome (KFS) includes craniocervical anomalies, low posterior hairline, and brevicollis, with limited cervical range of motion; however, there remains no consensus on inheritance pattern. This study defines incidence, characterizes concurrent diagnoses, and examines trends in the presentation and management of KFS. Methods: This was a retrospective review of the Kid's Inpatient Database (KID) for KFSpatients aged 0–20 years from 2003 to 2012. Incidence was established using KID-supplied year and hospital-trend weights. Demographics and secondary diagnoses associated with KFS were evaluated. Comorbidities, anomalies, and procedure type trends from 2003 to 2012 were assessed for likelihood to increase among the years studied using ANOVA tests. Results: Eight hundred and fifty-eight KFS diagnoses (age: 9.49 years; 51.1% females) and 475 patients with congenital fusion (CF) (age: 8.33 years; 50.3% females) were analyzed. We identified an incidence rate of 1/21,587 discharges. Only 6.36% of KFS patients were diagnosed with Sprengel's deformity; 1.44% with congenital fusion. About 19.1% of KFS patients presented with another spinal abnormality and 34.0% presented with another neuromuscular anomaly. About 36.51% of KFS patients were diagnosed with a nonspinal or nonmusculoskeletal anomaly, with the most prevalent anomalies being of cardiac origin (12.95%). About 7.34% of KFS patients underwent anterior fusions, whereas 6.64% of KFS patients underwent posterior fusions. The average number of levels operated on was 4.99 with 8.28% receiving decompressions. Interbody devices were used in 2.45% of cases. The rate of fusions with

Study design A cross-sectional study. Objective The goal of this study is to investigate how surgeons differ in collar and narcotic use, as well as return to driving recommendations following cervical spine surgeries and the associated medico-legal ramifications of these conditions. Summary of background data Restoration of quality of life is one of the main goals of cervical spine surgery. Patients frequently inquire when they may safely resume driving after cervical spine surgery. There is no consensus regarding postoperative driving restrictions. This study addresses how surgeons differ in their recommendations concerning cervical immobilization, narcotic analgesia, and suggested timeline of return to driving following cervical spine surgery. Methods Surgeons at the Cervical Spine Research Society annual meeting completed anonymous surveys assessing postoperative patient management following fusion and nonfusion cervical spine surgeries. Results Seventy percent of surgeons returned completed surveys (n = 71). About 80.3% were orthopedic surgeons and 94.2% completed a spine fellowship. Experienced surgeons (>15 years in practice) were more likely to let patients return to driving within 2 weeks than less experienced surgeons (47.1% vs. 24.3%, P = 0.013) for multilevel anterior discectomy and fusion (ACDF) and laminectomy with fusion procedures. There were no differences between surgeons practicing inside and outside the USA for prescribing collars or return to driving time. Cervical collars were used more for fusions than nonfusions (57.7% vs. 31.0%, P = 0.001). Surgeons reported 75.3% of patients ask when they may resume driving. For cervical fusions, 31.4% of surgeons allowed their patients to resume driving while restricting them with collars for longer durations. Furthermore, 27.5% of surgeons allowed their patients to resume driving while taking narcotics postoperatively. Conclusion This survey-based study highlights the lack of consensus regarding patient "fitness to drive" following cervical spine surgery. The importance of establishing evidence-based guidelines is critical, as recommendations for driving in the postoperative period may have significant medical, legal, and financial implications. Level of evidence 5.

Background: Informed patient selection and counseling is key in improving surgical outcomes. Understanding the impact that certain baseline variables can have on postoperative outcomes is essential in optimizing treatment for certain symptoms, such as radiculopathy from cervical spine pathologies. The aim was to identify baseline characteristics that were related to improved or worsened postoperative outcomes for patients undergoing surgery for cervical spine radiculopathic pain. Methods: Retrospective review of prospectively collected data. Patient Sample: Surgical cervical spine patients with a diagnosis classification of “degenerative.” Diagnoses included in the “degenerative” category were those that caused radiculopathy: cervical disc herniation, cervical stenosis, and cervical spondylosis without myelopathy. Baseline variables considered as predictors were: (1) age, (2) body mass index (BMI), (3) gender, (4) history of cervical spine surgery, (5) baseline Neck Disability Index (NDI) score, (6) baseline SF-36 Physical Component Summary (PCS) scores, (7) baseline SF-36 Mental Component Summary (MCS) scores, (8) Visual Analog Scale (VAS) Arm score, and (9) VAS Neck. Outcome Measures: Improvement in NDI (≥50%), VAS Arm/Neck (≥50%), SF-36 PCS/MCS (≥10%) scores at 2-years postoperative. An arm-to-neck ratio (ANR) was also generated from baseline VAS scores. Univariate and multivariate analyses evaluated predictors for 2-year postoperative outcome improvements, controlling for surgical complications and technique. Results: Three hundred ninety-eight patients were included. Patients with ANR ≤ 1 (n = 214) were less likely to reach improvements in 2-year NDI (30.0% vs 39.2%, P = .050) and SF-36 PCS (42.4% vs 53.5%, P = .025). Multivariate analysis for neck disability revealed higher baseline SF-36 PCS (odds ratio [OR] 1.053) and MCS (OR 1.028) were associated with over 50% improvements. Higher baseline NDI were reduced odds of postoperative neck pain improvement (OR 0.958). Arm pain greater than neck pain at baseline was associated with both increased odds of postoperative arm pain improvement (OR 1.707) and SF36 PCS improvement (OR 1.495). Conclusions: This study identified specific symptom locations and health-related quality of life (HRQL) scores, which were associated with postoperative pain and disability improvement. In particular, baseline arm pain greater than neck pain was determined to have the greatest impact on whether patients met at least 50% improvement in their upper body pain score. These findings are important for clinicians to optimize patient outcomes through effective preoperative counseling.

INTRODUCTION: Early Onset and Adolescent Idiopathic Scoliosis, relatively common diagnoses (∼3% general population), have been associated with developmental dysplasia of the hip (DDH); a more rare spectrum of anomalies related to the abnormal development of acetabulum, proximal femur, and hip joint. To the best of our knowledge, no high powered investigations have been performed in an attempt to assess incidence and associated risks of DDH in scoliosis patients. METHODS: The KID database was queried for ICD-9 codes from 2003 to 2012 pertaining to EOS (Congenital and Idiopathic 0.05 between groups) developed hip osteonecrosis, 0% of patients were coded as having a hip labral tear, hip ankylosis, and 0.6% (EOS: 0.2%; AIS: 0.9%, p = 0.025) developed hip osteoarthritis. AIS patients were more likely to have recurrent hip dislocations (35.4% vs 17.0%, p

Retrospective radiographic review. To understand the effect of variability in sacral endplate selection in transitional lumbosacral vertebrae (TLSV) and its impact on pelvic, regional, and global spinal alignment parameters. TLSV can have the characteristics of both lumbar and sacral vertebrae. Difficulties in identification of the S1 endplate may come from nomenclature, number of lumbar vertebrae, sacra, and morphology and may influence the interpretation and consistency of spinal alignment parameters. Patients with TLSV were identified and radiographic measurements including pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), sagittal vertical axis (SVA), T1-pelvic angle (TPA), pelvic incidence-lumbar lordosis (PI-LL) mismatch, thoracic kyphosis (TK), and spinal inclination (T1SPi) were obtained. Radiographic measurements were performed twice with the sacral endplate at the cephalad and caudal options. Paired t tests assessed the difference between different selection groups. Of 1,869 patients, 70 (3.7%) were found to have TLSV on radiographic imaging. Fifty-eight (82.9%) had lumbarized sacral segments whereas 12 (17.1%) had sacralized lumbar segments. T1-SPi (mean: −1.77°) and TK (mean: 34.86°) did not vary from altering sacral endplate selection. Selection of the caudal TLSV as the sacral endplate resulted in an increase in all pelvic parameters (PI: 66.8° vs. 44.3°, PT: 25.1° vs. 12.7°, and SS: 41.6° vs. 31.6°), regional lumbar parameters (LL: −54.1° vs. 44.0°, PI-LL: 12.7° vs. 0.3°), and global parameters (SVA: 46.1 mm vs. 28.3 mm, TPA: 23.3° vs. 10.8°) as compared to selecting the cephalad TLSV. All mean differences between radiographic parameters were found to be statistically significant (p < .001). Variation in sacral endplate selection in TLSV significantly affects spinal alignment parameter measurements. A standardized method for measuring TLSV is needed to reduce measurement error and ultimately allow more accurate understanding of alignment targets in patients with TLSV. Level III.

Cardiac anomalies are prevalent in patients with bony spinal anomalies. Prior studies evaluating incidences of bony congenital anomalies of the spine are limited. The Kids’ Inpatient Database (KID) yields national discharge estimates of rare pediatric conditions like congenital disorders. This study utilized cluster analysis to study patterns of concurrent vertebral anomalies, anal atresia, cardiac malformations, trachea-esophageal fistula, renal dysplasia, and limb anomalies (VACTERL anomalies) co-occurring in patients with spinal congenital anomalies. Retrospective review of KID 2003–2012. KID-supplied hospital- and year-adjusted weights allowed for incidence assessment of bony spinal anomalies and cardiac, gastrointestinal, urinary anomalies of VACTERL. K-means clustering assessed relationships between most frequent anomalies within bony spinal anomaly discharges; k set to n − 1(n = first incidence of significant drop/little gain in sum of square errors within clusters). There were 12,039,432 KID patients 0–20 years. Incidence per 100,000 discharges: 2.5 congenital fusion of spine, 10.4 hemivertebra, 7.0 missing vertebra. The most common anomalies co-occurring with bony vertebral malformations were atrial septal defect (ASD 12.3%), large intestinal atresia (LIA 11.8%), and patent ductus arteriosus (PDA 10.4%). Top congenital cardiac anomalies in vertebral anomaly patients were ASD, PDA, and ventricular septal defect (VSD); all three anomalies co-occur at 6.6% rate in this vertebral anomaly population. Cluster analysis revealed that of bony anomaly discharges, 55.9% of those with PDA had ASD, 34.2% with VSD had PDA, 22.9% with LIA had ASD, 37.2% with ureter obstruction had LIA, and 35.5% with renal dysplasia had LIA. In vertebral anomaly patients, the most common co-occurring congenital anomalies were cardiac, renal, and gastrointestinal. Top congenital cardiac anomalies in vertebral anomaly patients were ASD, PDA, and VSD. VACTERL patients with vertebral anomalies commonly presented alongside cardiac and renal anomalies.

Sagittal spinal deformity (SSD) patients utilize pelvic tilt (PT) and their lower extremities in order to compensate for malalignment. This study examines the effect of hip osteoarthritis (OA) on compensatory mechanisms in SSD patients.Patients ≥ 18 years with SSD were included for analysis. Spinopelvic, lower extremity, and cervical alignment were assessed on standing full-body stereoradiographs. Hip OA severity was graded by Kellgren-Lawrence scale (0-4). Patients were categorized as limited osteoarthritis (LOA: grade 0-2) and severe osteoarthritis (SOA: grade 3-4). Patients were matched for age and T1-pelvic angle (TPA). Spinopelvic [sagittal vertical axis (SVA), T1-pelvic angle, thoracic kyphosis (TK), pelvic tilt (PT), lumbar lordosis (LL), pelvic incidence minus lumbar lordosis (PI-LL), T1-spinopelvic inclination (T1SPi)] and lower extremity parameters [sacrofemoral angle, knee angle, ankle angle, posterior pelvic shift (P. Shift), global sagittal axis (GSA)] were compared between groups using independent sample t test.136 patients (LOA = 68, SOA = 68) were included in the study. SOA had less pelvic tilt (p = 0.011), thoracic kyphosis (p = 0.007), and higher SVA and T1Spi (p 0.001) than LOA. SOA had lower sacrofemoral angle (p 0.001) and ankle angle (p = 0.043), increased P. Shift (p 0.001) and increased GSA (p 0.001) compared to LOA. There were no differences in PI-LL, LL, knee angle, or cervical alignment (p 0.05).Patients with coexisting spinal malalignment and SOA compensate by pelvic shift and thoracic hypokyphosis rather than PT, likely as a result of limited hip extension secondary to SOA. As a result, SOA had worse global sagittal alignment than their LOA counterparts. These slides can be retrieved under Electronic Supplementary Material.

BACKGROUND: Regional and segmental changes of the lumbar spine have previously been described as patients transition from standing to sitting; however, alignment changes in the cervical and thoracic spine have yet to be investigated. So, the aim of this study was to assess cervical and thoracic regional and segmental changes in patients with thoracolumbar deformity versus a nondeformed thoracolumbar spine population. METHODS: This study was a retrospective cohort study of a single center's database of full-body stereoradiographic imaging and clinical data. Patients were ≥ 18 years old with nondeformed spines (nondegenerative, nondeformity spinal pathologies) or thoracolumbar deformity (ASD: PI-LL > 10°). Patients were propensity-score matched for age and maximum hip osteoarthritis grade and were stratified by Scoliosis Research Society (SRS)–Schwab classification by PI-LL, SVA, and PT. Patients with lumbar transitional anatomy or fusions were excluded. Outcome measures included changes between standing and sitting in global alignment parameters: sagittal vertical axis (SVA), pelvic incidence minus lumbar lordosis (PI-LL), pelivc tilt (PT), thoracic kyphosis, cervical alignment, cervical SVA, C2-C7 lordosis (CL), T1 slop minus CL (TS-CL), and segmental alignment from C2 to T12. Another analysis was performed using patients with cervical and thoracic segmental measurements. RESULTS: A total of 338 patients were included (202 nondeformity, 136 ASD). After propensity-score matching, 162 patients were included (81 nondeformity, 81 ASD). When categorized by SRS-Schwab classification, all nondeformity patients were nonpathologically grouped for PI-LL, SVA, and PT, whereas ASD patients had mix of moderately and markedly deformed modifiers. There were significant differences in pelvic and global spinal alignment changes from standing to sitting between nondeformity and ASD patients, particularly for SVA (nondeformed: 49.5 mm versus ASD: 27.4 mm; P&thinsp

BACKGROUND: Given the paucity of literature regarding compensatory mechanisms used by obese patients with sagittal malalignment, it is necessary to gain a better understanding of the effects of obesity on compensation after comparing the degree of malalignment to age-adjusted ideals. This study aims to compare baseline alignment of obese and nonobese patients using age-adjusted spino-pelvic alignment parameters, describing associated spinal changes. METHODS: Patients ≥ 18 years with full-body stereoradiographs were propensity-score matched for sex, baseline pelvic incidence (PI), and categorized as nonobese (body mass index

Many preventive methodologies seek to reduce the risk of surgical site infections after total knee arthroplasty (TKA), including the use of preoperative chlorhexidine baths and cloths. Although we have demonstrated in previous studies that this may be an efficacious method for infection prevention, our study was underpowered and we therefore set out to evaluate this with a larger sample size.(1) Does a preadmission chlorhexidine cloth skin preparation protocol decrease the risk of surgical site infection in patients undergoing TKA? (2) When stratified using the National Healthcare Safety Network (NHSN) risk categories, which categories are associated with risk reduction from the preadmission chlorhexidine preparation protocol?In our study, all patients (3717 total) who had undergone primary or revision TKA at a single institution between January 1, 2007, and December 31, 2013, were identified, of whom 991 patients used the chlorhexidine cloths before surgery and 2726 patients did not. All patients were provided cloths with instructions before surgery; however, as a result of a lack of compliance, we were able to substratify patients into treatment and control cohorts. Additionally, we substratified patients by NHSN risk category to determine differences in infection between the two cohorts (cloth versus no cloth). Patient medical records and an infection-tracking database were reviewed to determine the development of periprosthetic infection (patients who had superficial infections were excluded from our study) in both groups after 1 year surveillance. We then calculated relative risk reductions with use of chlorhexidine gluconate and stratified results based on NHSN risk category.Use of a preoperative chlorhexidine cloth skin preparation protocol is associated with reduced relative risk of periprosthetic infection after TKA (infections with protocol: three of 991 [0.3%]; infections in control: 52 of 2726 [1.9%]; relative risk [RR]: 6.3 [95% confidence interval [CI], 1.9-20.1]; p = 0.002). When stratified by NHSN risk category, periprosthetic infection risk reduction was seen in the medium-risk category (protocol: one of 402 [0.3%]; control: 25 of 1218 [2.0%]; RR, 8.3 [CI, 1.1-60.7]; p = 0.038), but no significant difference was detected in the low- and medium-risk groups (RR, 2.1 [CI, 0.5-9.6; p = 0.33] and RR, 11.3 [CI, 0.7-186.7; p = 0.09]).A prehospital chlorhexidine gluconate wipe protocol appears to reduce the risk of periprosthetic infections after TKA, primarily in those patients with medium and high risk. Although future multicenter randomized trials will need to confirm these preliminary findings, the intervention is inexpensive and is unlikely to be risky and therefore might be considered on the basis of this retrospective, comparative study.Level III, therapeutic study.

Background: The study aimed to characterize trends in incidence, etiology, fracture types, surgical procedures, complications, and concurrent injuries associated with traumatic pediatric cervical fracture using a nationwide database. Methods: The Kids9 Inpatient Database (KID) was queried. Trauma cases from 2003 to 2012 were identified, and cervical fracture patients were isolated. Demographics, etiologies, fracture levels, procedures, complications, and concurrent injuries were assessed. The t-tests elucidated significance for continuous variables, and χ2 for categoric values. Logistic regressions identified predictors of spinal cord injury (SCI), surgery, any complication, and mortality. Level of significance was P Results: A total of 11 196 fracture patients were isolated (age, 16.63 years; male, 65.7%; white, 65.4%; adolescent, 55.4%). Incidence significantly increased since 2003 (2003 vs 2012, 2.39% vs 3.12%, respectively), as did Charlson Comorbidity Index (CCI; 2003 vs 2012, 0.2012 vs 0.4408, respectively). Most common etiology was motor vehicle accidents (50.5%). Infants and children frequently fractured at C2 (closed: 43.1%, 32.9%); adolescents and young adults frequently fractured at C7 (closed: 23.9%, 26.5%). Upper cervical SCI was less common (5.8%) than lower cervical SCI (10.9%). Lower cervical unspecified-SCI, anterior cord syndrome, and other specified SCIs significantly decreased since 2003. Complications were common (acute respiratory distress syndrome, 7.8%; anemia, 6.7%; shock, 3.0%; and mortality, 4.2%), with bowel complications, cauda equina, anemia, and shock rates significantly increasing since 2003. Concurrent injuries were common (15.2% ribs; 14.4% skull; 7.1% pelvis) and have significantly increased since 2003. Predictors of SCI included sports injury and CCI. Predictors of surgery included falls, sports injuries, CCI, length of stay, and SCI. CCI, SCIs, and concurrent injuries were predictors of any complication and mortality, all (P Conclusions: Since 2003, incidence, complications, concurrent injuries, and fusions have increased. CCI, SCI, falls, and sports injuries were significant predictors of surgical intervention. Decreased mortality and SCI rates may indicate improving emergency medical services and management guidelines. Level of Evidence: III Clinical Relevance: Clinicians should be aware of increased case complexity in the onset of added perioperative complications and concurrent injuries. Cervical fractures resultant of sports injuries should be scrutinized for concurrent SCIs.

Retrospective review from a single institution.To investigate the effect of hip osteoarthritis (OA) on spinopelvic compensatory mechanisms as a result of reduced hip range of motion (ROM) between sitting and standing.Hip OA results in reduced hip ROM and contracture, causing pain during postural changes. Hip flexion contracture is known to reduce the ability to compensate for spinal deformity while standing; however, the effects of postural spinal alignment change between sitting and standing is not well understood.Sit-stand radiographs of patients without prior spinal fusion or hip prosthesis were evaluated. Hip OA was graded by Kellgren-Lawrence grades and divided into low-grade (LOA; grade 0-2) and severe (SOA; grade 3 or 4) groups. Radiographic parameters evaluated were pelvic incidence (PI), pelvic tilt (PT), lumbar lordosis (LL), PI-LL, thoracic kyphosis (TK), SVA, T1-pelvic angle (TPA), T10-L2, proximal femoral shaft angle (PFSA), and hip flexion (PT change-PFSA change). Changes in sit-stand parameters were compared between LOA and SOA groups.548 patients were included (LOA = 311; SOA = 237). After propensity score matching for age, body mass index, and PI, 183 LOA and 183 SOA patients were analyzed. Standing analysis demonstrated that SOA had higher SVA (31.1 vs. 21.7), lower TK (-36.2 vs. -41.1), and larger PFSA (9.1 vs. 7.4) (all p.05). Sitting analysis demonstrated that SOA had higher PT (29.7 vs. 23.3), higher PI-LL (21.6 vs. 12.4), less LL (31.7 vs. 41.6), less TK (-33.2 vs. -38.6), and greater TPA (27.9 vs. 22.5) (all p.05). SOA had less hip ROM from standing to sitting versus LOA (71.5 vs. 81.6) (p.05). Therefore, SOA had more change in PT (15.2 vs. 7.3), PI-LL (20.6 vs. 13.7), LL (-21.4 vs. -13.1), and T10-L2 (-4.9 vs. -1.1) (all p.001), allowing the femurs to change position despite reduced hip ROM. SOA had greater TPA reduction (15.1 vs. 9.6) and less PFSA change (86.7 vs. 88.8) compared with LOA (both p.001).Spinopelvic compensatory mechanisms are adapted for reduced hip joint motion associated with hip OA in standing and sitting.Level III.

Surgical decompression using laminoplasty is commonly performed for multilevel stenosis with cervical spondylotic myelopathy. However, the long-term effects on the craniocervical range of motion (ROM) after surgery are not well understood. This study represents the first entry into the literature of photogrammetric analysis for clinical measurement of craniocervical ROM. All patients underwent a French-door laminoplasty from 1995 to 2016 and were evaluated radiologically and with postoperative photographs (photogrammetric analysis) to measure craniocervical ROM and axial rotation. Radiographic parameters were occiput to C2 angle, C1–2 angle, C2–7 angle/cervical lordosis (CL), T1-slope (T1S), and TS-CL were measured. Chin-brow vertical angle (CBVA) was utilized for flexion and extension, while nose-turn angle (NTA) was used to assess axial rotation. Forty-four patients (mean age: 65.7 years, 50% female) had a mean follow-up of 37.9 months. Mean values in neutral, flexion, and extension were occiput to C2 = 30°, 15°, and 43°; C1–C2 = −32°, −25°, −32°; and C2–C7 = −4°, 11°, −20°, respectively. Mean CL was within 1 SD of the established −17° (±13.86°). Mean T1S and TS-CL were 33° and 30° in the neutral position, respectively. Mean radiographic full range of motion from flexion to extension was 53°. NTA towards patients’ left was 48° and the right side was 45°. Mean CBVA, was −4°, mean flexion 37°, and extension −45°; full range was 81°. Global craniocervical ROM has proven to be well preserved for many years following cervical laminoplasty. Photogrammetric analysis is a cost-effective and radiation-free method, accurate for quantitative assessment of craniocervical and cervical ROM.

Introduction This study assessed the incidence and risk factors for pseudarthrosis among primary spine fusion patients. Methods Retrospective review of ACS-NSQIP (2005–2013). Differences in comorbidities between spine fusion patients with and without pseudarthrosis (Pseud, N-Pseud) were assessed using chi-squared tests and Independent Samples t-tests. Binary logistic regression assessed patient-related and procedure-related predictors for pseudarthrosis. Results 52,402 patients (57yrs, 53%F, 0.4% w/pseudarthrosis). Alcohol consumption (OR:2.6[1.2–5.7]) and prior history of surgical revision (OR:1.6[1.4–1.8]) were risk factors for pseudarthrosis operation. Pseud patients at higher risk for deep incisional SSI (at 30-days:OR:6.6[2.0–21.8]). Pseud patients had more perioperative complications (avg:0.24 ± 0.43v0.18 ± 0.39,p=0.026). Conclusions Alcoholism and surgical revision are major risk factors for pseudarthrosis in patients undergoing spine fusion.

BACKGROUND CONTEXT Chin-Brow Vertical Angle (CBVA) is not routinely measured on radiographs even though it is a strong assessor of horizontal gaze. STUDY DESIGN Retrospective cohort study of patients with full-body stereoradiographs and a primary cervical diagnosis at the time of presentation. PURPOSE Assess the utility of McGregor's Slope (McGS) and Slope of Line of Sight (SLS) as surrogate markers for the CBVA in cervical spine pathology. METHODS A retrospective review of patients with full-body stereoradiographs was performed. Patients were ≥18 years of age with a primary cervical diagnosis. Analysis of CBVA, McGS, and SLS was conducted as markers of horizontal gaze. Sagittal alignment was characterized by: pelvic tilt (PT), pelvic incidence minus lumbar lordosis (PI-LL), T1-pelvic angle (TPA), sagittal vertical axis (SVA), T2-T12 thoracic kyphosis, C2-C7 SVA (cSVA), C2-C7 Cervical lordosis, T1-Slope minus Cervical Lordosis (TS-CL), and C2-Slope (C2S). A subgroup analysis was performed in patients with cervical deformity. Independent sample t tests and paired t tests compared radiographic alignment. Pearson correlations characterized linear relationships. Linear regression analysis identified relationships between the parameters. RESULTS In all, 329 patients were identified with primary cervical spine diagnoses. Chin-Brow Vertical Angle was visible in 171 patients (52.0%), McGS in 281 (85.4%), and SLS in 259 (78.7%). Of the 171 patients with visible CBVA, the mean CBVA was 2.30±7.7, mean McGS was 5.02±8.1, and mean SLS was −1.588±2.03. Chin-Brow Vertical Angle strongly correlated with McGS (r=0.83) and SLS (r=0.89) with p CONCLUSIONS This study demonstrates that McGS and SLS serve as strong, positive correlates for CBVA. The reported mean differences between these measurements provide a useful conversion, broadening CBVA's use as a radiographic assessment of horizontal gaze.

Background Risk of death is important in counseling patients and improving quality of care. Incidence of death in cervical surgery is not firmly established due to its rarity and limited sample sizes, particularly in the context of different surgeries, demographics, and risk factors. Particularly, different patient risk profiles may have varying degrees of risk in terms of surgeries, comorbidities, and demographics. This study aims to use a large patient cohort available on a national database to study the prevalence of death associated with cervical spine surgery. Methods This study was a retrospective review of the Nationwide Inpatient Sample (NIS) years 2003–2012. A total of 342 477 patients were identified by International Classification of Diseases, Ninth Revision, Clinical Modification codes undergoing spinal fusion or decompression for disc degeneration, stenosis, spondylosis, myelopathy, postlaminectomy syndrome, scoliosis, or neck pain associated with the cervical region. Patients with malignancy were excluded from analysis. Incidence of mortality was assessed by χ2 tests across different patient demographics and comorbidities, procedures performed, and concurrent in-hospital complications. Binary logistic regression identified significant increases or decreases in risk of death while controlling for comorbidities, race, sex, and Mirza invasiveness. Significance was defined as P Results The study analyzed 342 477 patients with an overall mortality rate of 0.32%. A total of 231 977 simple fusions (single approach and Conclusion In 342 477 cervical spine surgery patients an overall mortality rate of 0.32% was reported. The rate was 3.91% in a cohort of 5933 patients with congestive heart failure and 3.79% in a cohort of 6947 patients with paraplegia. These findings are consistent with previous estimates and may help counsel patients and improve in-hospital safety. Level of Evidence 3

Background: This study aims to describe properties of adult spinal deformity (ASD) revisions relative to primary surgeries and determine clinical variables that can predict revision. ASD is a common pathology that can lead to decreased quality of life, pain, physical limitations, and dissatisfaction with self-image. Durability of interventions for deformity treatment is of paramount concern to surgeons, as revision rates remain high. Methods: Patients undergoing thoracolumbar fusion, five or more levels, for scoliosis (primary diagnosis ICD-9 737.x) were identified on a state-wide database. Primary and revision (returning for re-fusion procedure) surgeries were compared based on demographic, hospital stay, and clinical characteristics. Differences between primary and revision surgeries, and predictors of primary surgeries requiring revision, utilized binary logistic regression controlling for age, comorbidity burden, and levels fused. Results: A total of 1,063 patients (average 7.4 levels fused, mean age: 47.6 years, 69.0% female) undergoing operative treatment for ASD were identified, of which 123 (average 7.1 levels fused, 11.6%, mean age 61.43, 80.5% female) had surgical revision. Primary surgeries were ~0.3 levels longer (P=0.013), used interbody ~11% more frequently (P=0.020), and used BMP ~12% less frequently (P=0.008). Revisions occurred 176.4 days after the primary on average. The most frequent causes of revisions were: 43.09% implant failure, 24.39% acquired kyphosis, and 14.63% enduring scoliosis. After controlling for age, comorbidities, and levels fused older, more comorbid, female, and white-race patients were more likely to be revised. Upon multivariate regression, after controlling for age and levels fused, overall complications remained non-different (OR: 0.8, 95% CI: 0.6–1.2). However, revision remained an independent predictor for infection (OR: 5.5, 95% CI: 2.8–10.5). Conclusions: In a statewide database with individual patient follow up of up to 4 years 10% of ASD patients undergoing scoliosis correction required revision. Revision surgeries had higher infection incidence.

The impact of obesity on global spinopelvic alignment is poorly understood. This study investigated the effect of body mass index on achieving alignment targets and compensation mechanisms after corrective surgery for adult spinal deformity (ASD).Retrospective review of a single-center database. Inclusion: patients ≥18 years with full-body stereographic images (baseline and 1 year) and who met ASD criteria (sagittal vertical axis [SVA]5 cm, pelvic incidence minus lumbar lordosis [PI-LL]10°, coronal curvature20° or pelvic tilt20°). Patients were stratified by age (40, 40-65, and ≥65 years) and body mass index (25, 25-30, and30). Postoperative alignment was compared with age-adjusted ideal values. Prevalence of patients who matched ideals and unmatched (undercorrected/overcorrected) was assessed. Health-related quality of life (HRQL) scores, alignment, and compensatory mechanisms were compared across cohorts using analysis of variance and temporally with paired t tests.A total of 116 patients were included (average age, 62 years; 66% female). After corrective surgery, obese and overweight patients had more residual malalignment (worse PI-LL, T1 pelvic angle, pelvic tilt, and SVA) compared with normal patients (P0.05). In addition, obese and overweight patients recruited more pelvic shift (obese, 62.36; overweight, 49.80; normal, 31.50) and had a higher global sagittal angle (obese, 6.51; overweight, 6.35; normal, 3.40) (P0.05). Obese and overweight patients showed lower overcorrection rates and higher undercorrection rates (P0.05). Obese patients showed worse postoperative HRQL scores (Scoliosis Research Society 22 Questionnaire, Oswestry Disability Index, visual analog scale-leg) than did overweight and normal patients (P0.05). Obese and overweight patients who matched age-adjusted alignment targets for SVA or PI-LL showed no HRQL improvements (P0.05).After surgery, obese patients were undercorrected, showed more residual malalignment, recruited more pelvic shift, and had a greater global sagittal angle and worse HRQL scores. The benefits from age-adjusted alignment targets seem to be less substantial for obese and overweight patients.

Study Design: Retrospective cohort study. Objectives: The purpose of this study was to report incidence of cardiopulmonary complications in elective spine surgery, demographic and surgical predictors, and outcomes. Understanding the risks and predictors of these sentinel events is important for risk evaluation, allocation of hospital resources, and counseling patients. Methods: A retrospective review of the National Surgical Quality Improvement Program (NSQIP) was performed on 60 964 patients undergoing elective spine surgery (any region; laminectomy, arthrodesis, discectomy, or laminoplasty) between 2011 and 2013. Incidence of myocardial infarction, cardiac arrest, unplanned reintubation, on ventilator >48 hours, perioperative pneumonia, and pulmonary embolism was measured. Demographic and surgical predictors of cardiopulmonary complications and associated outcomes (length of stay, discharge disposition, and mortality) were measured using binary logistic regression controlling for confounders. Results: Incidence rates per 1000 elective spine patients were 2.1 myocardial infarctions, 1.3 cardiac arrests, 4.3 unplanned intubations, 3.5 on ventilator >48 hours, 6.1 perioperative pneumonia, and 3.7 pulmonary embolisms. In analysis of procedure, diagnosis, and approach risk factors, thoracic cavity (odds ratio = 2.47; confidence interval = 1.95-3.12), scoliosis diagnosis, and combined approach (odds ratio = 1.51; confidence interval = 1.15-1.96) independently added the most risk for cardiopulmonary complication. Cardiac arrest had the highest mortality rate (34.57%). Being on ventilator greater than 48 hours resulted in the greatest increase to length of stay (17.58 days). Conclusions: Expected risk factors seen in the Revised Cardiac Risk Index were applicable in the context of spine surgery. Surgical planning should take into account patients who are at higher risk for cardiopulmonary complications and the implications they have on patient outcome.

Background: Chiari malformations type 1 (CM-1), a developmental anomaly of the posterior fossa, usually presents in adolescence or early adulthood. There are few studies on the national incidence of CM-1, taking into account outcomes based on concurrent diagnoses. To quantify trends in CM-1 treatment and associated diagnoses. Retrospective review of the Kids’ Inpatient Database (KID) from 2003–2012. Methods: Patients, aged 0–20, with primary diagnosis of CM-1 in the KID database were identified. Demographics and concurrent diagnoses were analyzed using chi-squared and t-tests for categorical and numerical variables, respectively. Trends in diagnosis, treatments, and outcomes were analyzed using analysis of variance (ANOVA). Results: Five thousand four hundred and thirty-eight patients were identified in the KID database with primary diagnosis of CM-1 (10.5 years, 55% female). CM-1 primary diagnoses have increased over time (45 to 96 per 100,000). CM-1 patients had the following concurrent diagnoses: 23.8% syringomyelia/syringobulbia, 11.5% scoliosis, 5.9% hydrocephalus, 2.2% tethered cord syndrome. Eighty-three point four percent of CM-1 patients underwent surgical treatment, and rate of surgical treatment for CM-1 increased from 2003–2012 (66% to 72%, P vs . 4.7%). Seven point four percent of patients experienced at least one peri-operative complication (nervous system, dysphagia, respiratory most common). Patients with concurrent hydrocephalus had increased nervous and respiratory systems, urinary, and respiratory complications (P Conclusions: CM-1 malformation diagnoses have increased in the last decade. Despite the decrease in overall complication rates, fusions are becoming more common and are associated with higher peri-operative complication rates. Commonly associated diagnoses including syringomyelia and hydrocephalus, can dramatically increase experienced complication rates.

Study Design Retrospective review of KID Inpatient Database (KID) from 2003, 2006, 2009, and 2012. Objectives The aim of this study was to evaluate the impact of advances in spinal surgery on patient outcomes in the treatment of Scheuermann kyphosis (SK). Summary of Background Data SK is one of the most common causes of back pain in adolescents. Trends in diagnoses and surgical treatment and approach to SK have not been well described. Methods SK patients aged 0–20 years in KID were identified by ICD-9 code 732.0. KID-supplied year- and hospital-trend weights were used to establish prevalence. Patient demographics, surgical details, and outcomes were analyzed with analysis of variance. Results A total of 1,070 SK patients were identified (33.2% female), with increasing incidence of SK diagnosed from 2003 to 2012 (3.6–7.5 per 100,000, p < .001). The average age of operative patients was 16.1±2.0 years and did not change (16.27–16.06 years, p = .905). The surgical rate has not changed over time (72.8%–72.8%, p = .909). Overall, 96.3% of operative patients underwent fusion, with 82.2% of cases spanning ⩾4 levels; in addition, 8.6% underwent an anterior-only surgery, 74.6% posterior-only, and 13.6% combined approach. From 2003 to 2012, rates of posterior-only surgeries increased (62.4%–84.4%, p < .001) whereas the rate of combined-approach surgeries decreased (37.6%–8.8%, p < .001). Overall complication rates for SK surgeries have decreased (2003: 20.9%; 2012: 11.9%, p = .029). Concurrently, the rate of ⩾4-level fusions has increased (43.5%–89.6%, p < .001), as well as the use of Smith-Peterson (7.8%–23.6%, p < .001) and three-column osteotomies (0.0%–2.7%, p = .011). In subanalysis comparing posterior to combined approaches, complication rates were significantly different (posterior: 9.88%, combined: 19.46%, p = .005). Patients undergoing a combined approach have a longer length of stay (LOS) than patients undergoing a posterior-only approach (7.8 vs. 5.6 days, p < .001). Conclusions Despite unchanged demographics and operative rates in SK, there has been a shift from combined to isolated posterior approaches, with a concurrent increase in levels treated. A combined approach was associated with increased complication rates, LOS, and total charges compared to isolated approaches. Awareness of these inherent differences is important for surgical decision making and patient education. Levels of Evidence Level III.

The causes and epidemiology of traumatic cervical spine fracture have not been described with sufficient power or recency. Our goal is to describe demographics, incidence, cause, spinal cord injuries (SCIs), concurrent injuries, treatments, and complications of traumatic cervical spine fractures.A retrospective review was carried out of the Nationwide Inpatient Sample. International Classification of Disease, Ninth Revision E-codes identified trauma cases from 2005 to 2013. Patients with cervical fracture were isolated. Demographics, incidence, cause, fracture levels, concurrent injuries, surgical procedures, and complications were analyzed. t tests elucidated significance for continuous variables and χA total of 488,262 patients were isolated (age, 55.96 years; male, 60.0%; white, 77.5%). Incidence (2005, 4.1% vs. 2013, 5.4%), Charlson Comorbidity Index (2005, 0.6150 vs. 2013, 1.1178), and total charges (2005, $71,228.60 vs. 2013, $108,119.29) have increased since 2005, whereas length of stay decreased (2005, 9.22 vs. 2013, 7.86) (all P 0.05). The most common causes were motor vehicle accident (29.3%), falls (23.7%), and pedestrian accidents (15.7%). The most frequent fracture types were closed at C2 (32.0%) and C7 (20.9%). Concurrent injury rates have significantly increased since 2005 (2005, 62.3% vs. 2013, 67.6%). Common concurrent injuries included fractures to the rib/sternum/larynx/trachea (19.6%). Overall fusion rates have increased since 2005 (2005, 15.7% vs. 2013, 18.0%), whereas decompressions and halo insertion rates have decreased (all P0.05). SCIs have significantly decreased since 2005, except for upper cervical central cord syndrome. Complication rates have significantly increased since 2005 (2005, 31.6% vs. 2013, 36.2%). Common complications included anemia (7.7%), mortality (6.6%), and acute respiratory distress syndrome (6.6%).Incidence, complications, concurrent injuries, and fusions have increased since 2005. Length of stay, SCIs, decompressions, and halo insertions have decreased. Indicated trends should guide future research in management guidelines.

Study DesignRetrospective radiological review.PurposeTo quantify the effect of sitting vs supine lumbar spine magnetic resonance imaging (MRI) and change in anterior displacement of the psoas muscle from L1–L2 to L4–L5 discs.Overview of LiteratureControversy exists in determining patient suitability for lateral lumbar interbody fusion (LLIF) based on psoas morphology. The effect of posture on psoas morphology has not previously been studied; however, lumbar MRI may be performed in sitting or supine positions.MethodsA retrospective review of a single-spine practice over 6 months was performed, identifying patients aged between 18–90 years with degenerative spinal pathologies and lumbar MRIs were evaluated. Previous lumbar fusion, scoliosis, neuromuscular disease, skeletal immaturity, or intrinsic abnormalities of the psoas muscle were excluded. The anteroposterior (AP) dimension of the psoas muscle and intervertebral disc were measured at each intervertebral disc from L1–L2 to L4–L5, and the AP psoas:disc ratio calculated. The morphology was compared between patients undergoing sitting and/or supine MRI.ResultsTwo hundred and nine patients were identified with supine-, and 60 patients with sitting-MRIs, of which 13 patients had undergone both sitting and supine MRIs (BOTH group). A propensity score match (PSM) was performed for patients undergoing either supine or sitting MRI to match for age, BMI, and gender to produce two groups of 43 patients. In the BOTH and PSM group, sitting MRI displayed significantly higher AP psoas:disc ratio compared with supine MRI at all intervertebral levels except L1–L2. The largest difference observed was a mean 32%–37% increase in sitting AP psoas:disc ratio at the L4–L5 disc in sitting compared to supine in the BOTH group (range, 0%–137%).ConclusionsThe psoas muscle and the lumbar plexus become anteriorly displaced in sitting MRIs, with a greater effect noted at caudal intervertebral discs. This may have implications in selecting suitability for LLIF, and intra-operative patient positioning.

Introduction Posterior C1-C2 fusion is a highly successful treatment for atlantoaxial instability and other pathologies of the cervical spine, with fusion rates approaching 95%-100%. However, poor visualization of the lateral masses of C1 secondary to the course of the C2 nerve root along with blood loss from the venous plexus and compression of the C2 nerve from lateral mass screws are technical obstacles that can arise during surgery. Thus, sacrifice of the C2 nerve root has long since been debated in fusions involving the C1 and C2 vertebral bodies. Methods Cadaveric dissections on four adult specimens were performed. Both intradural and extradural courses of C2 were studied in detail. The tentative site of C2 nerve root compression during placement of C1 lateral mass screws was studied in detail. Both the indication as well as the ease of C2 neurectomy were studied in relation to postoperative compression and entrapment. Results Four-six dorsal rootlets of C2 nerve were observed while studying the intradural course. The extradural course was studied with respect to the lateral mass of C1. The greater occipital nerve (GON) course was fairly consistent in all specimens. Transection of C2 around its ganglion would allow for proper C1 lateral mass screw placement as the course of C2 nerve interferes with proper placement of instrumentation. Conclusion C2 nerve root transection is associated with occipital numbness but this often has no effect on health-related quality of life (HRQOL). The C2 nerve root preservation is often associated with entrapment neuropathy or occipital neuralgia, which greatly affects HRQOL. The C2 nerve root transection helps in better visualization, aids in optimal placement of C1 lateral mass screws, minimizes estimated blood loss and improves surgical outcome with successful fusion.

BACKGROUND CONTEXT Spinopelvic compensatory mechanisms for reduced hip motion (ROM) in the setting of hip osteoarthritis. PURPOSE Hip osteoarthritis (OA) results in reduced hip range of motion, which affects sitting and standing posture. Spinal pathology (eg, fusion or deformity) may alter the ability to compensate for reduced joint mobility associated with hip OA in sitting and standing postures; however, the effect of hip OA on postural spinal alignment between sitting and standing remains unreported. In patients with severe hip OA, spinopelvic compensatory mechanisms can be compromised leading to greater pelvic tilt (PT) and lumbar lordosis (LL) change. STUDY DESIGN/SETTING Retrospective clinical and radiographic analysis at a single institution of patients with OA between 2012 and 2017. PATIENT SAMPLE A total of 548 patients with sit-stand radiographs. OUTCOME MEASURES Spinal and lower limb alignment Pelvic Incidence (PI), PT, LL, PI-LL, Thoracic Kyphosis (TK), Global alignment (SVA & T1-Pelvic Angle (TPA), T10-L2, proximal femoral shaft angle (PFSA: as measured from the vertical), sacrofemoral angle (SFA), Knee Flexion (KA) and hip ROM (difference between PT change and PFSA change). METHODS Hip OA severity was graded by Kellgren-Lawrence scale and divided into two groups: low-grade (LOA; grades 0-2) and severe (SOA; grades 3-4). Patients were excluded if they had transitional lumbosacral anatomy, prior spinal fusion or hip prosthesis. Changes in sit-stand alignment were compared between LOA and SOA by unpaired t-test RESULTS A total of 548 patients were identified with sit-stand radiographs, of which there were 311 patients with LOA and 237 with SOA. After propensity score matching for age, BMI, PI and standing SVA, 183 LOA & 183 SOA patients were analyzed. Standing alignment analysis demonstrated that SOA patients had lower PT (14.49 ± 9.2 vs. 16.78 ± 8.14, p CONCLUSIONS Spinopelvic compensatory mechanisms are adapted for reduced hip ROM in SOA between standing and sitting. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Recent research has identified increased C2-T3 angle as a risk factor for persistent sagittal malalignment following thoracolumbar surgery. Despite this, no ideal cervicothoracic alignment thresholds exist in the literature. As several studies have demonstrated a clear relationship between the normal aging spine and sagittal spinal alignment, such ideal-alignment thresholds should also account for patient age. PURPOSE This study proposes age-specific cervicothoracic alignment targets using previously published age-specific normative Neck Disability Index (NDI) values. STUDY DESIGN/SETTING Single center retrospective review. PATIENT SAMPLE A total of 223 patients with available biplanar full-body stereographic x-rays. OUTCOME MEASURES C2-T3 lordosis; Neck Disability Index score. METHODS Patients >18 years with cervical sagittal vertical axis RESULTS Overall, 223 patients (50±20years, 65% F) met inclusion criteria, presenting with a mean sagittal vertical axis (SVA) of 17.8±47.7 mm, cervical SVA 19.8±11.2 mm, T1 Slope-C2-C7 lordosis 24.7°±16.2°, and C2-T3 of 2.1°±16.5°. At baseline, increased C2-T3 angle was significantly correlated with both NDI score (r=0.266, p 75 years: 27.8. Liner regression analysis showed a significant relationship between NDI score, age, and baseline cervicothoracic alignment, as assessed by C2-T3 angle (r=0.497, p 75 years: 6.7°. CONCLUSIONS Significant relationships exist between age, neck disability, and cervicothoracic alignment, suggesting broad measurements across the cervicothoracic junction may be clinically relevant in predicting postoperative outcomes of surgical spine deformity patients. Taking into account patient age and USA-normative values of neck disability, this study offers a set of ideal age-adjusted alignment targets for C2-T3. By proposing a set of normative, age-specific cervicothoracic alignment targets, this study better facilitates individual optimization of surgical planning.

BACKGROUND CONTEXT Standing spinal alignment has been the center of focus recently, particularly in the setting of adult spinal deformity. While lumbopelvic sagittal alignment has been shown to adapt from standing to sitting posture, segmental vertebral alignment of the entire spine is not yet fully understood, nor the effects of degeneration (DEGEN) or flatback deformity (DEFORMITY). Segmental spinal alignment between sitting and standing and the effects of DEGEN and DEFORMITY was analyzed. PURPOSE To determine how sitting and standing segmental spinal alignment are altered with lumbar DEGEN and DEFORMITY compared to patients with NORMAL lumbar spines. STUDY DESIGN/SETTING Retrospective radiographic review. PATIENT SAMPLE A total of 491 patients with full body sitting & standing radiographs at a single institution. OUTCOME MEASURES Segmental spinal alignment & lumbopelvic alignment (pelvic tilt [PT], pelvic incidence [PI], lumbar lordosis [LL], PI-LL, sacral slope). METHODS Lumbar spines were classified as NORMAL, DEGEN (at least one level of disc height loss >50%, facet arthropathy, or spondylolisthesis) or DEFORMITY (PI-LL mismatch>10°). Exclusion criteria included lumbar fusion or ankylosis, hip arthroplasty, and transitional lumbosacral anatomy. Independent samples t-tests analyzed lumbopelvic and segmental alignment between sitting and standing within groups. ANOVA assessed these differences between spine pathology groups. RESULTS There were 183 NORMAL, 216 DEGEN and 92 DEFORMITY patients with significant differences in age, gender and hip OA grades. After propensity matching for these factors, there were 56 patients in each group (age 63±14, 58% female). Significant differences were noted between spinal pathology groups with regard to changes from standing and sitting alignment with regard to NORMAL versus DEGEN versus DEFORMITY groups: Standing: Significant differences were noted in PT(13.13° vs. 14.08° vs. 24.30°, p CONCLUSIONS The lower lumbar spine provides the greatest sitting to standing change in lumbopelvic alignment in normal patients. Degeneration and deformity of the spine significantly reduces the mobility of the lower lumbar spine and PT. With lumbar spine degeneration and flatback deformity, relatively more alignment change occurs at the upper lumbar spine and thoracolumbar junction FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Multilevel fusions and complex osteotomies to restore global alignment in adult spinal deformity (ASD) surgery can lead to significant blood loss intra- and postoperatively. Increasing levels of blood transfusion may be related to multiple adverse surgical outcomes including infection, venous thrombosis, and mortality. In this regard, managing blood loss and perioperative transfusion in ASD surgery is an important concern. An awareness of potential risk factors for transfusion can optimize preoperative preparation, and perioperative management. PURPOSE The aim of this study is to identify preoperative and intraoperative patient and surgical characteristics predicting the need for blood transfusion in ASD surgery. STUDY DESIGN/SETTING Retrospective review of prospectively collected single center database. PATIENT SAMPLE A total of 418 patients (Age: 56±18 years; 283F, 135 M; BMI: 27±6, ASA: 2.4±0.6, Levels fused: 10.8±4.2) were included in the analysis. OUTCOME MEASURES Estimated blood loss (EBL), percent blood volume (BV) lost, volume of cell salvaged blood returned, red blood cell (RBC) transfusions, and perioperative hemoglobin levels were derived from chart review. METHODS We assessed a single center multisurgeon database of 418 ASD patients, age>18years, with greater than four levels fused. Preoperative and intraoperative patient and surgical characteristics were collected by chart review. Factors predictive of blood loss, and intra- and perioperative transfusion were assessed. RESULTS A total of 418 ASD patients were included in the analysis. 246/418 (59%) patients received at least 1U RBCs intraoperatively. 94/418 (23%) patients received at least 1U RBCs postoperatively. With regards to intraoperative transfusion, each level fused was associated with an additional 0.17U RBC transfused (p 6.45hours was associated with an additional 0.24U RBCs transfused (p=.001), and pelvic fixation was associated with an additional 0.14U RBCs transfused (p=.039). There was no effect seen of number of units of RBCs transfused on surgical site or other infections. CONCLUSIONS Identification of predictors for percent blood volume lost and transfusion may facilitate preoperative planning and perioperative management. This study demonstrates that number of levels fused, 3CO, pelvic fixation, interbody fusion, preoperative hemoglobin 6.45hours were independent predictors of perioperative transfusion, and percent blood volume lost.

BACKGROUND CONTEXT A T1 Slope minus cervical lordosis (TS-CL) angle of 20° has been described in the literature as a significant cutoff to define cervical deformity, however recent studies suggest that this cutoff needs to be redefined. PURPOSE The aim of this study was to develop a novel TS-CL threshold indicative of moderate to severe cervical disability. STUDY DESIGN/SETTING Single-center retrospective review. PATIENT SAMPLE A total of 69 cervical patients indicated for surgical treatment were included. OUTCOME MEASURES T1 slope minus cervical lordosis, neck disability index (NDI). METHODS Patients age 18years old with a primary cervical diagnosis indicated for surgical treatment were included. Patients with active infection, tumors or trauma were excluded. We tested possible cutoffs for TS-CL against the percentage of individuals meeting normative, mild, moderate (>25) and severe (>35) NDI scores at baseline. The TS-CL cutoff with the highest sensitivity to predict a normative, mild, moderate (>25) and severe (>35) NDI score was selected. RESULTS A total of 69 cervical patients indicated for surgical treatment were included (mean age 55.4±9.9years, 45% female, mean BMI 29.1±6.6 kg/m2). The average baseline NDI score was 39.9±20.9 for this cohort. At baseline, average TS-CL was 27.3°±18.8°, CL was 1.7°±17.6°, cSVA was 28.3 mm±17.3 mm. Spino-pelvic alignment parameters at baseline were as follows: PT 16.1°±8.3°, PI-LL −2.8°±11.9°, TK 38.8°±12.7° and SVA −6.3 mm±51.8 mm. Using previously established TS-CL severity breakdowns, 13 (18.8%) patients had mild TS-CL ( 20°). Using this cutoff of 20° as severe TS-CL, it did not correlate with NDI score (P=.390). After testing possible cutoffs of TS-CL that relate to moderate to severe NDI scores, a novel cutoff of 30.65° for TS-CL was related to an NDI score of ³25 points. CONCLUSIONS In a cohort of cervical surgery patients, a novel cutoff of 30.65°for TS-CL was predictive of moderate to severe neck disability, as described as an NDI score greater than or equal to 25 points. This criterion can be applied to cervical spine patients to better assess cervical disability.

Patient satisfaction has emerged as a critical metric in assessing patient-reported outcomes for healthcare services. The importance of accurately measuring satisfaction is evidenced by the implementation of patient-reported satisfaction as a tool for healthcare reimbursement by the Centers for Medicare and Medicaid Services (CMS). The Patient Protection and Affordable Care Act have formalized the grading of healthcare quality using patient-centric outcomes. Additionally, data indicate that patient satisfaction is directly governed by patient expectations and this expectation-actuality relationship may have a profound impact on patient outcomes. Healthcare providers must have an understanding of the parameters used to measure patient satisfaction and of the associated impact that treatment satisfaction has on patient-reported outcome measures (PROMs). The purpose of this manuscript is to provide a brief overview of how patient satisfaction is defined and measured and to evaluate the implications of poor patient satisfaction on patient-reported outcomes and perceived surgical success. Additionally, we explore the clinical utility of measuring satisfaction on an institutional scale.