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STUDY DESIGN.: Epidemiologic study using national administrative data. OBJECTIVE.: To compare anterior cervical discectomy and fusion (ACDF) with cervical disc arthroplasty (CDA) for the treatment of cervical disc pathology in terms of (1) patient and hospital characteristics, length of stay, and total charges; and (2) temporal changes in those variables and in overall numbers. SUMMARY OF BACKGROUND DATA.: Studies have shown that CDA has results and safety profiles comparable with those of ACDF, but information on patient and hospital characteristics and economical impact of CDA is lacking. METHODS.: We queried the Nationwide Inpatient Sample for all hospitalization records from 2005 through 2008 with International Classification of Diseases, Ninth Revision, Clinical Modification codes corresponding to ACDF or CDA, used multivariable linear regression analyses (significance, P, 0.05) for patient and hospital characteristics, and calculated length of stay parameters. For total hospital charges, we used the consumer price index to convert all charges to 2008 US dollars. RESULTS.: Most of the 544,174 ACDF procedures occurred in the South; most of the 4,710 CDA procedures occurred in the West and South. Compared with patients undergoing ACDF, those undergoing CDA were younger (P, 0.001). Comorbid severity for ACDF increased over time (P, 0.001) but did not change for CDA (P = 0.664). Although hospital stay decreased for both groups, total hospital charges increased for ACDF but remained stable for CDA over time. CONCLUSION.: Patients undergoing CDA tended to be younger and to have less comorbidity, shorter hospital stays, and lower costs. The number of CDAs increased over time, although the percentage remained relatively small in comparison with that for ACDF. [ABSTRACT FROM AUTHOR]

Background: The minimum clinically important difference is a clinically relevant threshold of improvement. A substantial clinical benefit is a threshold of change that correlates with clinically important improvement. The Cervical Spine Outcomes Questionnaire is a disease-specific, patient-reported outcomes instrument that was developed to be sensitive to changes associated with surgical treatment for degenerative cervical disc disease. To determine thresholds for change in these domain scores that are important from the patient's perspective, we estimated the minimum clinically important difference and substantial clinical benefit values for this questionnaire's domain scores.Methods: We evaluated 252 patients from the Cervical Spine Research Society Outcomes Study at their six-month follow-up visits after anterior cervical spine decompression and arthrodesis. Using a receiver operating characteristics curve, with the health transition item of the Short Form-36 as an anchor, we determined that the minimum clinically important difference (the value that maximized sensitivity and specificity to differentiate the "somewhat better" and "much better" responses from others) and the substantial clinical benefit (the value that maximized sensitivity and specificity to differentiate the "much better" response from others) for our questionnaire's domain scores. Responses were scaled between 0 and 1 point; higher scores denoted more severe impairment. Patient and clinical characteristics were tested to determine their influence on score changes.Results: The minimum clinically important difference ranged from 0.13 point (for functional disability) to 0.24 point (for arm/shoulder pain). The substantial clinical benefit score ranged from 0.20 point (for functional disability or physical symptoms other than pain) to 0.30 point (for neck or arm/shoulder pain). Age, sex, and duration of current symptoms were not associated with change in our questionnaire's domain scores.Conclusions: A 0.13-point change in the functional disability domain score indicated a clinically important difference in a self-reported outcome after anterior cervical spine surgery. A 0.30-point change in neck pain after surgery indicated a clinically important clinical benefit. This information, coupled with previous reports of the psychometric stability of the Cervical Spine Outcomes Questionnaire, should increase the clinical utility of this patient-reported outcomes instrument. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Retrospective cross-sectional study. OBJECTIVE: To determine the role of race, insurance status, and geographic location on US anterior cervical spine surgery rates and in-hospital mortality between 1992 and 2005. SUMMARY OF BACKGROUND DATA: Previous investigation indicates that anterior cervical spine surgery has been increasingly used in the management of degenerative cervical spine disease throughout the 1990s. Significant predictors of health outcomes, including race, ethnicity, geography, and insurance coverage have yet to be investigated in detail for these procedures. METHODS: Cases of anterior cervical spine surgery were identified from the Nationwide Inpatient Sample. The US population counts were taken from the Current Population Survey. Multivariate regression models were employed to describe national rates of anterior cervical spine surgery and model the odds of death among admissions for anterior cervical spine surgery. All models incorporated adjustment for hospital sample clustering, age, and comorbidity status. RESULTS: Based on an analysis of a total 100,286,482 hospital discharge records, an estimated 965,600 anterior cervical spine procedures were performed between 1992 and 2005 in the United States. During this period, rates of surgery increased by 289%. Though adjusted rates of surgery were lowest among minority populations, disparities decreased with time. The mean age of patients, as well as the average preoperative comorbidity status, increased with time. The odds of mortality did not significantly increase between 1992 and 2005. Odds of in-hospital death were greatest in among black patients (P < 0.001) and lowest in Southern states (P < 0.001) and patients with private insurance (P < 0.001). CONCLUSION: With the recent rise of anterior cervical spine procedures in the United States, substantial variation in the delivery of surgical care exists along a number of demographic factors. A detailed investigation of variation in surgical decision-making algorithms among spine specialists, as well as a determination of differences among patient populations in attitudes toward surgery, may help elucidate the trends observed in this study. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective analysis of the incidence and prevalence of dysphagia after anterior cervical decompression and fusion (ACDF).Objectives: To examine the incidence and prevalence of dysphagia after ACDF, determine possible associated patient and procedural characteristics, and examine dysphagia's impact on long-term health status and function.Summary Of Background Data: Dysphagia is a common early complaint after ACDF, but the risk factors associated with its development are not understood.Methods: Telephone surveys (Cervical Spine Outcomes Questionnaire) and clinical assessments (Oswestry Neck Disability Scale and SF-36) were used to evaluate 454 patients who had undergone ACDF at one of 23 nationwide sites for individual and procedure characteristics that might contribute to dysphagia.Results: Of the 454 patients, 30% reported dysphagia at the 3-month assessment (incident cases). The incidence of new complaints of dysphagia at each follow-up point was 29.8%, 6.9%, and 6.6% at 3, 6, and 24 months, respectively. Dysphagia persisted at 6 and 24 months in 21.5% and 21.3% of patients, respectively. The risk of dysphagia increased with number of surgical vertebral levels at 3 months: 1 level, 42 of 212 (19.8%); 2 levels, 50 of 150 (33.3%); 3+ levels, 36 of 92 (39.1%). Patients reporting dysphagia at 3 months had a significantly higher self-reported disability and lower physical health status at subsequent assessments.Conclusion: Duration of preexisting pain and the number of vertebral levels involved in the surgical procedure appear to influence the likelihood of dysphagia after ACDF. [ABSTRACT FROM AUTHOR]

Study Design: A retrospective analysis., Objective: The aim of our study was to analyze the association of Area Deprivation Index (ADI) with the utilization and costs of elective anterior cervical discectomy and fusion (ACDF) surgery., Summary of Background Data: ADI, a comprehensive neighborhood-level measure of socioeconomic disadvantage, has been shown to be associated with worse perioperative outcomes in a variety of surgical settings., Materials and Methods: The Maryland Health Services Cost Review Commission Database was queried to identify patients who underwent primary elective ACDF between 2013 and 2020 in the state. Patients were stratified into tertiles by ADI, from least disadvantaged (ADI1) to most disadvantaged (ADI3). The primary endpoints were ACDF utilization rates per 100,000 adults and episode-of-care total costs. Univariable and multivariable regression analyses were performed., Results: A total of 13,362 patients (4984 inpatient and 8378 outpatient) underwent primary ACDF during the study period. In our study, there were 2,401 (17.97%) patients residing in ADI1 neighborhoods (least deprived), 5974 (44.71%) in ADI2, and 4987 (37.32%) in ADI3 (most deprived). Factors associated with increased surgical utilization were increasing ADI, outpatient surgical setting, non-Hispanic ethnicity, current tobacco use, and diagnoses of obesity and gastroesophageal reflux disease. Factors associated with lower surgical utilization were: non-white race, rurality, Medicare/Medicaid insurance status, and diagnoses of cervical disk herniation or myelopathy. Factors associated with higher costs of care were increasing ADI, older age, Black/African American race, Medicare or Medicaid insurance, former tobacco use, and diagnoses of ischemic heart disease and cervical myelopathy. Factors associated with lower costs of care were outpatient surgical setting, female sex, and diagnoses of gastroesophageal reflux disease and cervical disk herniation., Conclusions: Neighborhood socioeconomic deprivation is associated with increased episode-of-care costs in patients undergoing ACDF surgery. Interestingly, we found greater utilization of ACDF surgery among patients with higher ADI., Level of Evidence: 3., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background Context: Pain self-efficacy, or the belief that one can carry out activities despite pain, has been shown to be associated with back and neck pain severity. However, the literature correlating psychosocial factors to opioid use, barriers to proper opioid use, and Patient-Reported Outcome Measurement Information System (PROMIS) scores is sparse., Purpose: The primary aim of this study was to determine whether pain self-efficacy is associated with daily opioid use in patients presenting for spine surgery. The secondary aim was to determine whether there exists a threshold self-efficacy score that is predictive of daily preoperative opioid use and subsequently to correlate this threshold score with opioid beliefs, disability, resilience, patient activation, and PROMIS scores., Patient Sample: Five hundred seventy-eight elective spine surgery patients (286 females; mean age of 55 years) from a single institution were included in this study., Study Design/setting: Retrospective review of prospectively collected data., Outcome Measures: PROMIS scores, daily opioid use, opioid beliefs, disability, patient activation, resilience., Methods: Elective spine surgery patients at a single institution completed questionnaires preoperatively. Pain self-efficacy was measured by the Pain Self-Efficacy Questionnaire (PSEQ). Threshold linear regression with Bayesian information criteria was utilized to identify the optimal threshold associated with daily opioid use. Multivariable analysis controlled for age, sex, education, income, and Oswestry Disability Index (ODI) and PROMIS-29, version 2 scores., Results: Of 578 patients, 100 (17.3%) reported daily opioid use. Threshold regression identified a PSEQ cutoff score of <22 as predictive of daily opioid use. On multivariable logistic regression, patients with a PSEQ score <22 had two times greater odds of being daily opioid users than those with a score ≥22. Further, PSEQ <22 was associated with lower patient activation; increased leg and back pain; higher ODI; higher PROMIS pain, fatigue, depression, and sleep scores; and lower PROMIS physical function and social satisfaction scores (p<.05 for all)., Conclusions: In patients presenting for elective spine surgery, a PSEQ score of <22 is associated with twice the odds of reporting daily opioid use. Further, this threshold is associated with greater pain, disability, fatigue, and depression. A PSEQ score <22 can identify patients at high risk for daily opioid use and can guide targeted rehabilitation to optimize postoperative quality of life., Competing Interests: Declaration of competing interests One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Study Design: Retrospective review of prospectively collected data., Objective: To assess the association between preoperative and postoperative mental health status with postoperative satisfaction in lumbar degenerative surgery patients., Summary of Background Data: Poor preoperative mental health has been shown to negatively affect postoperative satisfaction among spine surgery patients, but there is limited evidence on the impact of postoperative mental health on satisfaction., Materials and Methods: Adult patients undergoing surgery for lumbar degenerative conditions at a single institution were included. Mental health was assessed preoperatively and 12 months postoperatively using Patient-Reported Outcomes Measurement Information System Depression and Anxiety scores. Satisfaction was assessed 12 months postoperatively using North American Spine Society Patient Satisfaction Index. The authors evaluated associations between mental health and satisfaction with univariate and multivariable logistic regression to adjust for confounders. Preoperative depression/anxiety level was corrected for postoperative depression/anxiety level, and vice versa. Statistical significance was assessed at α=0.05., Results: A total of 183 patients (47% male individuals; avg. age, 62 y) were included. Depression was present in 27% preoperatively and 29% postoperatively, and anxiety in 50% preoperatively and 31% postoperatively. Ninteen percent reported postoperative dissatisfaction using the North American Spine Society Patient Satisfaction Index. Univariate analysis identified race, family income, relationship status, current smoking status, change in pain interference, and change in physical function as potential confounders. In adjusted analysis, odds of dissatisfaction were increased in those with mild postoperative depression (adjusted odds ratio=6.1; 95% confidence interval, 1.2-32; P=0.03) and moderate or severe postoperative depression (adjusted odds ratio=7.5; 95% confidence interval, 1.3-52; P=0.03). Preoperative and postoperative anxiety and preoperative depression were not associated with postoperative satisfaction., Conclusions: Following lumbar degenerative surgery, patients with postoperative depression, irrespective of preoperative depression status, have significantly higher odds of dissatisfaction. These results emphasize the importance of postoperative screening and treatment of depression in spine patients with dissatisfaction., Level of Evidence: Level III-nonrandomized cohort study., Competing Interests: R.R. received grant (TL1 TR003100) from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH), and the NIH Roadmap for Medical Research. The remaining authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The purpose of this study was to investigate the longitudinal postoperative relationship between physical activity, psychosocial factors, and physical function in patients undergoing lumbar spine surgery., Methods: We enrolled 248 participants undergoing surgery for a degenerative lumbar spine condition. Physical activity was measured using a triaxial accelerometer (Actigraph GT3X) at 6-weeks (6wk), 6-months (6M), 12-months (12M) and 24-months (24M) following spine surgery. Physical function (computerized adaptive test domain version of Patient-Reported Outcomes Measurement Information System) and psychosocial factors (pain self-efficacy, depression and fear of movement) were assessed at preoperative visit and 6wk, 6M, 12M and 24M after surgery. Structural equation modeling (SEM) techniques were utilized to analyze data, and results are represented as standardized regression weights (SRW). Overall SRW were computed across five imputed datasets to account for missing data. The mediation effect of each psychosocial factor on the effect of physical activity on physical function were computed [(SRW for effect of activity on psychosocial factor X SRW for effect of psychosocial factor on function) ÷ SRW for effect of activity on function]. Each SEM model was tested for model fit by assessing established fit indexes., Results: The overall effect of steps per day on physical function (SRW ranged from 0.08 to 0.19, p<0.05) was stronger compared to the overall effect of physical function on steps per day (SRW ranged from non-existent to 0.14, p<0.01 to 0.3). The effect of steps per day on physical function and function on steps per day remained consistent after accounting for psychosocial factors in each of the mediation models. Depression and fear of movement at 6M mediated 3.4% and 5.4% of the effect of steps per day at 6wk on physical function at 12M, respectively. Pain self-efficacy was not a statistically significant mediator., Conclusions: The findings of this study suggest that the relationship between physical activity and physical function is stronger than the relationship of function to activity. However, future research is needed to examine whether promoting physical activity during the early postoperative period may result in improvement of long-term physical function. Since depression and fear of movement had a very small mediating effect, additional work is needed to investigate other potential mediating factors such as pain catastrophizing, resilience and exercise self-efficacy., (© 2021. The Author(s).)

Objective: To investigate whether early postoperative walking is associated with "best outcome" and no opioid use at 1 year after lumbar spine surgery and establish a threshold for steps/day to inform clinical practice., Design: Secondary analysis from randomized controlled trial., Setting: Two academic medical centers in the United States., Participants: We enrolled 248 participants undergoing surgery for a degenerative lumbar spine condition (N=248). A total of 212 participants (mean age, 62.8±11.4y, 53.3% female) had valid walking data at baseline., Interventions: Not applicable., Main Outcome Measures: Disability (Oswestry Disability Index), back and leg pain (Brief Pain Inventory), and opioid use (yes vs no) were assessed at baseline and 1 year after surgery. "Best outcome" was defined as Oswestry Disability Index ≤20, back pain ≤2, and leg pain ≤2. Steps/day (walking) was assessed with an accelerometer worn for at least 3 days and 10 h/d at 6 weeks after spine surgery, which was considered as study baseline. Separate multivariable logistic regression analyses were conducted to determine the association between steps/day at 6 weeks and "best outcome" and no opioid use at 1-year. Receiver operating characteristic curves identified a steps/day threshold for achieving outcomes., Results: Each additional 1000 steps/d at 6 weeks after spine surgery was associated with 41% higher odds of achieving "best outcome" (95% confidence interval [CI], 1.15-1.74) and 38% higher odds of no opioid use (95% CI, 1.09-1.76) at 1 year. Walking ≥3500 steps/d was associated with 3.75 times the odds (95% CI, 1.56-9.02) of achieving "best outcome" and 2.37 times the odds (95% CI, 1.07-5.24) of not using opioids., Conclusions: Walking early after surgery may optimize patient-reported outcomes after lumbar spine surgery. A 3500 steps/d threshold may serve as an initial recommendation during early postoperative counseling., (Copyright © 2021 The American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background Context: Little is known about the effects of sleep disturbance (SD) on clinical outcomes after spine surgery., Purpose: To determine the (1) prevalence of SD among patients presenting for spine surgery at an academic medical center; (2) correlations between SD and health-related quality of life (HRQoL) scores; and (3) associations between postoperative SD resolution and short-term HRQoL., Study Design: Retrospective review of prospectively collected data., Patient Sample: We included 508 adults undergoing spine surgery at 1 academic center between December 2014 and January 2018., Outcome Measures: Participants completed the Oswestry Disability Index (ODI) or Neck Disability Index (NDI) and Patient Reported Outcome Measurement System (PROMIS-29) questionnaire preoperatively, during the immediate postoperative period (6-12 weeks), and at 6, 12, and 24 months after surgery., Methods: Using preoperative PROMIS SD scores, we grouped participants as having no sleep disturbance (score <55), mild disturbance (score, 55-60), moderate disturbance (score 60-70), or severe disturbance (score, 70). For the final analysis, we collapsed these categories into no/mild and moderate/severe. Pearson correlation tests were used to assess correlations between SD and HRQoL measures. Regression analysis (adjusting for age, sex, comorbidities, current opioid use, and occurrence of complications) was used to estimate the effect of postoperative resolved or continuing SD on HRQoL scores and the likelihood of achieving clinically meaningful improvements in HRQoL. Alpha = 0.05., Results: Preoperative SD was reported by 127 participants (25%). SD was significantly correlated with worse ODI and/or NDI values and worse scores in all PROMIS health domains (all, p<.001). At the immediate postoperative assessment, SD had resolved in 80 of 127 participants (63%). Compared with participants who reported no preoperative SD, those with ongoing SD were significantly less likely to achieve clinically meaningful improvements in Pain Interference (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.28, 0.84), Physical Function (OR, 0.32; 95% CI, 0.13, 0.82), and Satisfaction with Participation in Social Roles (OR, 0.57; 95% CI, 0.37, 0.80)., Conclusion: One-quarter of spine surgery patients reported preoperative SD of at least moderate severity. Poor preoperative sleep quality and ongoing postoperative sleep disturbance were significantly associated with worse scores on several HRQoL measures. These results highlight the importance of addressing patients' sleep disturbance both before and after surgery., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To identify spine patients' barriers to appropriate postoperative opioid use, comfort with naloxone, knowledge of safe opioid disposal practices, and associated factors., Methods: We preoperatively surveyed 174 spine patients about psychobehavioral barriers to appropriate opioid use, comfort with naloxone, and knowledge about opioid disposal. Multivariable logistic regression identified factors associated with barriers and knowledge (α = 0.05)., Results: Common barriers were fear of addiction (71%) and concern about disease progression (43%). Most patients (78%) had neutral/low confidence in the ability of nonopioid medications to control pain; most (57%) felt neutral or uncomfortable with using naloxone; and most (86%) were familiar with safe disposal. Anxiety was associated with fear of distracting the physician (adjusted odds ratio [aOR], 3.8; 95% confidence interval [CI], 1.1-14) and with lower odds of knowing safe disposal methods (aOR, 0.18; 95% CI, 0.04-0.72). Opioid use during the preceding month was associated with comfort with naloxone (aOR, 4.9; 95% CI, 2.1-12). Patients with a higher educational level had lower odds of reporting fear of distracting the physician (aOR, 0.30; 95% CI, 0.09-0.97), and those with previous postoperative opioid use had lower odds of concern about disease progression (aOR, 0.25; 95% CI, 0.09-0.63) and with a belief in tolerating pain (aOR, 0.34; 95% CI, 0.12-0.95)., Conclusions: Many spine patients report barriers to appropriate postoperative opioid use and are neutral or uncomfortable with naloxone. Some are unfamiliar with safe disposal. Associated factors include anxiety, lack of recent opioid use, and no previous postoperative use., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background Context: Positive psychosocial factors early after surgery, such as resilience and self-efficacy, may be important characteristics for informing individualized postoperative care., Purpose: To examine the association of early postoperative resilience and self-efficacy on 12-month physical function, pain interference, social participation, disability, pain intensity, and physical activity after lumbar spine surgery., Study Design/setting: Pooled secondary analysis of prospectively collected trial data from two academic medical centers., Patient Sample: Two hundred and forty-eight patients who underwent laminectomy with or without fusion for a degenerative lumbar condition., Outcome Measures: Physical function, pain inference, and social participation (ability to participate in social roles and activities) were measured using the Patient Reported Outcomes Measurement Information System. The Oswestry Disability Index, Numeric Rating Scale, and accelerometer activity counts were used to measure disability, pain intensity, and physical activity, respectively., Methods: Participants completed validated outcome questionnaires at 6 weeks (baseline) and 12 months after surgery. Baseline positive psychosocial factors included resilience (Brief Resilience Scale) and self-efficacy (Pain Self-Efficacy Questionnaire). Multivariable linear regression analyses were used to assess the associations between early postoperative psychosocial factors and 12-month outcomes adjusting for age, sex, study site, randomized group, fusion status, fear of movement (Tampa Scale for Kinesiophobia), and outcome score at baseline. This study was funded by Patient-Centered Outcomes Research Institute and Foundation for Physical Therapy Research. There are no conflicts of interest., Results: Resilience at 6 weeks after surgery was associated with 12-month physical function (unstandardized beta=1.85 [95% confidence interval [CI]: 0.29; 3.40]), pain interference (unstandardized beta=-1.80 [95% CI: -3.48; -0.12]), social participation (unstandardized beta=2.69 [95% CI: 0.97; 4.41]), and disability (unstandardized beta=-3.03 [95% CI: -6.04; -0.02]). Self-efficacy was associated with 12-month disability (unstandardized beta=-0.21 [95% CI: -0.37; -0.04]., Conclusions: Postoperative resilience and pain self-efficacy were associated with improved 12-month patient-reported outcomes after spine surgery. Future work should consider how early postoperative screening for positive psychosocial characteristics can enhance risk stratification and targeted rehabilitation management in patients undergoing spine surgery., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background Context: Since implementation of the Patient Protection and Affordable Care Act (ACA) in 2010, more Americans have health insurance, and many racial/ethnic disparities in healthcare have improved. We previously reported that Black and Hispanic patients undergo surgery for spinal stenosis at lower rates than do white patients., Purpose: To assess changes in racial/ethnic disparities in rates of lumbar spinal surgery after passage of the ACA., Study Design: Retrospective analysis., Patient Sample: Approximately 3.2 million adults who underwent lumbar spinal surgery in the US from 2006 through 2014., Outcome Measures: Racial disparities in discharge rates before versus after ACA passage., Methods: Using the Nationwide Inpatient Sample, the U.S. Census Bureau Current Population Survey Supplement, and International Classification of Diseases, Ninth Revision, Clinical Modification, criteria for definite lumbar spinal surgery, we calculated rates of lumbar spinal surgery as the number of hospital discharges divided by population estimates and stratified patients by race/ethnicity after controlling for sociodemographic characteristics. Calendar years were stratified as before ACA passage (2006-2010) or after ACA passage (2011-2014). Poisson regression was used to model hospital discharge rates as a function of race/ethnicity before and after ACA passage after adjustment for potential confounders., Results: All rates are expressed per 1,000 persons. The overall median discharge rate decreased from 1.9 before ACA passage to 1.6 after ACA passage (p < .001). After adjustment for sociodemographic factors, the Black:White disparity in discharge rates decreased from 0.40:1 before ACA to 0.44:1 after ACA (p < .001). A similar decrease in the Hispanic:White disparity occurred, from 0.35:1 before ACA to 0.38:1 after ACA (p < .001)., Conclusion: Small but significant decreases occurred in racial/ethnic disparities in hospital discharge rates for lumbar spinal surgery after ACA passage., (Copyright © 2020 Elsevier Inc. All rights reserved.)

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

Study Design: Secondary analysis of randomized controlled trial data., Objective: The aim of this study was to examine whether preoperative physical performance is an independent predictor of patient-reported disability and pain at 12 months after lumbar spine surgery., Summary of Background Data: Patient-reported outcome measures (PROMs) are commonly used to assess clinical improvement after lumbar spine surgery. However, there is evidence in the orthopedic literature to suggest that PROMs should be supplemented with physical performance tests to accurately evaluate long-term outcomes., Methods: A total of 248 patients undergoing surgery for degenerative lumbar spine conditions were recruited from two institutions. Physical performance tests (5-Chair Stand and Timed Up and Go) and PROMs of disability (Oswestry Disability Index: ODI) and back and leg pain (Brief Pain Inventory) were assessed preoperatively and at 12 months after surgery., Results: Physical performance tests and PROMs significantly improved over 12 months following lumbar spine surgery (P < 0.01). Weak correlations were found between physical performance tests and disability and pain (ρ = 0.15 to 0.32, P < 0.05). Multivariable regression analyses controlling for age, education, preoperative outcome score, fusion, previous spine surgery, depressive symptoms, and randomization group found that preoperative 5-Chair Stand test was significantly associated with disability and back pain at 12-month follow-up. Each additional 10 seconds needed to complete the 5-Chair Stand test were associated with six-point increase in ODI (P = 0.047) and one-point increase in back pain (P = 0.028) scores. The physical performance tests identified an additional 14% to 19% of patients as achieving clinical improvement that were not captured by disability or pain questionnaires., Conclusion: Results indicate that physical performance tests may provide distinct information in both predicting and assessing clinical outcomes in patients undergoing lumbar spine surgery. Our findings suggest that the 5-Chair Stand test may be a useful test to include within a comprehensive risk assessment before surgery and as an outcome measure at long-term follow-up., Level of Evidence: 3.

Background Context: Depression and anxiety are common psychiatric conditions among US adults, and anterior cervical discectomy and fusion (ACDF) is one of the most commonly performed spinal surgeries. Mental health conditions can affect physical health, and thus have the potential to contribute to adverse outcomes after spine surgery; however, a comprehensive assessment of long-term outcomes and the additive economic burden of these conditions in patients undergoing ACDF has not been well described., Purpose: Our goal was to assess the associations between depression/anxiety and adverse outcomes and health-resource utilization after anterior cervical discectomy and fusion (ACDF)., Study Design: Retrospective database study., Patient Sample: We retrospectively analyzed a private administrative health claims database to identify patients who underwent ACDF in the United States from 2010 to 2013. A total of 16,306 patients met our inclusion criteria. Mean (± standard deviation) patient age was 50±7.9 years. Approximately 4,800 patients (30%) had a depression diagnosis and 4,000 (25%) had a diagnosis of anxiety., Outcome Measures: The primary outcomes of interest were intensive care unit admission, multiday hospitalization, discharge disposition, 30- and 90-day hospital readmission, 1- and 2-year rates of revision surgery, and chronic postoperative opioid use. Secondary outcomes were 1- and 2-year total cumulative health care payments and cumulative postoperative opioid consumption., Methods: Regression models controlled for demographic and medical covariates, alpha=0.05., Results: A preoperative diagnosis of depression was associated with higher odds of multiday hospitalization (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.01-1.19), 90-day readmission (OR 1.71, 95% CI 1.46-2.02), revision surgery within 2 years (OR 1.43 95% CI 1.16-1.76), and chronic postoperative opioid use (OR 1.58, 95% CI 1.45-1.72) and an increase of $5,915 in adjusted 2-year health care payments (p<.001). Patients with a preoperative diagnosis of anxiety had higher odds of multiday hospitalization (OR 1.15, 95% CI 1.06-1.25), revision surgery within 2 years (OR 1.33, 95% CI 1.07-1.65), and chronic postoperative opioid use (OR 1.62, 95% CI 1.48-1.77) and an increase of $4,471 in adjusted 2-year health care payments (p<.001). Neither anxiety nor depression was associated with intensive care unit admission, discharge disposition, 30-day readmission, revision surgery within 1 year, 1-year cumulative health care payments, or cumulative postoperative opioid consumption., Conclusions: Patients with preoperative diagnoses of depression or anxiety have a greater likelihood of adverse outcomes, increased opioid consumption, and increased cumulative health care payments after ACDF compared with patients without depression or anxiety., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: The objectives of the study were to determine, among patients with adult spinal deformity (ASD), the following: 1) how preoperative opioid use, dose, and duration of use are associated with long-term opioid use and dose; 2) how preoperative opioid use is associated with rates of postoperative use from 6 weeks to 2 years; and 3) how postoperative opioid use at 6 months and 1 year is associated with use at 2 years., Methods: Using a single-center, longitudinally maintained registry, the authors identified 87 patients who underwent ASD surgery from 2013 to 2017. Fifty-nine patients reported preoperative opioid use (37 high-dose [≥ 90 morphine milligram equivalents daily] and 22 low-dose use). The duration of preoperative use was long-term (≥ 6 months) for 44 patients and short-term for 15. The authors evaluated postoperative opioid use at 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery. Multivariate logistic regression was used to determine associations of preoperative opioid use, dose, and duration with use at each time point (alpha = 0.05)., Results: The following preoperative factors were associated with opioid use 2 years postoperatively: any opioid use (adjusted odds ratio [aOR] 14, 95% CI 2.5-82), high-dose use (aOR 7.3, 95% CI 1.1-48), and long-term use (aOR 17, 95% CI 2.2-123). All patients who reported high-dose opioid use at the 2-year follow-up examination had also reported preoperative opioid use. Preoperative high-dose use (aOR 247, 95% CI 5.8-10,546) but not long-term use (aOR 4.0, 95% CI 0.18-91) was associated with high-dose use at the 2-year follow-up visit. Compared with patients who reported no preoperative use, those who reported preoperative opioid use had higher rates of use at each postoperative time point (from 94% vs 62% at 6 weeks to 54% vs 7.1% at 2 years) (all p < 0.001). Opioid use at 2 years was independently associated with use at 1 year (aOR 33, 95% CI 6.8-261) but not at 6 months (aOR 4.3, 95% CI 0.95-24)., Conclusions: Patients' preoperative opioid use, dose, and duration of use are associated with long-term use after ASD surgery, and a high preoperative dose is also associated with high-dose opioid use at the 2-year follow-up visit. Patients using opioids 1 year after ASD surgery may be at risk for long-term use.

Despite the use of digital technology in healthcare, telemedicine has not been readily adopted. During the COVID-19 pandemic, healthcare systems have begun crisis management planning. To appropriately allocate resources and prevent virus exposure while maintaining effective patient care, our orthopaedic surgery department rapidly introduced a robust telemedicine program during a 5-day period. Implementation requires attention to patient triage, technological resources, credentialing, education of providers and patients, scheduling, and regulatory considerations. This article provides practical instruction based on our experience for physicians who wish to implement telemedicine during the COVID-19 pandemic. Between telemedicine encounters and necessary in-person visits, providers may be able to achieve 50% of their typical clinic volume within 2 weeks. When handling the massive disruption to the routine patient care workflow, it is critical to understand the key factors associated with an accelerated introduction of telemedicine for the safe and effective continuation of orthopaedic care during this pandemic. LEVEL OF EVIDENCE:: V.

Objective: Care satisfaction is an important metric to health systems and payers. Patient activation is a hierarchical construct following 4 stages: 1) having a belief that taking an active role in their care is important, 2) having knowledge and skills to manage their condition, 3) having the confidence to make necessary behavioral changes, and 4) having an ability to maintain those changes in times of stress. The authors hypothesized that patients with a high level of activation, measured using the Patient Activation Measure (PAM), will be more engaged in their care and, therefore, will be more likely to be satisfied with the results of their surgical treatment., Methods: Using a prospectively collected registry at a multiprovider university practice, the authors examined patients who underwent elective surgery (n = 257) for cervical or lumbar spinal disorders. Patients were assessed before and after surgery (6 weeks and 3, 6, and 12 months) using Patient-Reported Outcomes Measurement Information System (PROMIS) health domains and the PAM. Satisfaction was assessed using the Patient Satisfaction Index. Using repeated-measures logistic regression, the authors compared the likelihood of being satisfied across stages of patient activation after adjusting for baseline characteristics (i.e., age, sex, race, education, income, and marital status)., Results: While a majority of patients endorsed the highest level of activation (56%), 51 (20%) endorsed the lower two stages (neither believing that taking an active role was important nor having the knowledge and skills to manage their condition). Preoperative patient activation was weakly correlated (r ≤ 0.2) with PROMIS health domains. The most activated patients were 3 times more likely to be satisfied with their treatment at 1 year (OR 3.23, 95% CI 1.8-5.8). Similarly, patients in the second-highest stage of activation also demonstrated significantly greater odds of being satisfied (OR 2.8, 95% CI 1.5-5.3)., Conclusions: Patients who are more engaged in their healthcare prior to elective spine surgery are significantly more likely to be satisfied with their postoperative outcome. Clinicians may want to implement previously proven techniques to increase patient activation in order to improve patient satisfaction following elective spine surgery.

Objective: The authors conducted a study to analyze associations between changes in depression/anxiety before and 12 months after spine surgery, as well as changes in scores using the Patient-Reported Outcomes Measurement Information System (PROMIS) at the same time points., Methods: Preoperatively and 12 months postoperatively, the authors assessed PROMIS scores for depression, anxiety, pain, physical function, sleep disturbance, and satisfaction with participation in social roles among 206 patients undergoing spine surgery for deformity correction or degenerative disease. Patients were stratified according to preoperative/postoperative changes in depression and anxiety, which were categorized as persistent, improved, newly developed postoperatively, or absent. Multivariate regression was used to control for confounders and to compare changes in patient-reported outcomes (PROs)., Results: Fifty patients (24%) had preoperative depression, which improved in 26 (52%). Ninety-four patients (46%) had preoperative anxiety, which improved in 70 (74%). Household income was the only preoperative characteristic that differed significantly between patients whose depression persisted and those whose depression improved. Compared with the no-depression group, patients with persistent depression had less improvement in all 4 domains, and patients with postoperatively developed depression had less improvement in pain, physical function, and satisfaction with social roles. Compared with the group of patients with postoperatively improved depression, patients with persistent depression had less improvement in pain and physical function, and patients with postoperatively developed depression had less improvement in pain. Compared with patients with no anxiety, those with persistent anxiety had less improvement in physical function, sleep disturbance, and satisfaction with social roles, and patients with postoperatively developed anxiety had less improvement in pain, physical function, and satisfaction with social roles. Compared with patients with postoperatively improved anxiety, patients with persistent anxiety had less improvement in pain, physical function, and satisfaction with social roles, and those with postoperatively developed anxiety had less improvement in pain, physical function, and satisfaction with social roles. All reported differences were significant at p < 0.05., Conclusions: Many spine surgery patients experienced postoperative improvements in depression/anxiety. Improvements in 12-month PROs were smaller among patients with persistent or postoperatively developed depression/anxiety compared with patients who had no depression or anxiety before or after surgery and those whose depression/anxiety improved after surgery. Postoperative changes in depression/anxiety may have a greater effect than preoperative depression/anxiety on changes in PROs after spine surgery. Addressing the mental health of spine surgery patients may improve postoperative PROs.■ CLASSIFICATION OF EVIDENCE Type of question: causation; study design: prospective cohort study; evidence: class III.

Study Design: Retrospective cohort study., Objective: To evaluate the risks and benefits of crossing the cervicothoracic junction (CTJ) in cervical arthrodesis., Summary of Background Data: Whether the CTJ should be crossed in cervical arthrodesis remains up for debate. Keeping C7 as the distal end of the fusion risks adjacent segment disease (ASD) and can result in myelopathy or radiculopathy. Longer fusions are thought to increase operative risk and complexity but result in lower rates of ASD., Materials and Methods: Patients undergoing cervical spine fusion surgery ending at C7 or T1 with ≥1-year follow-up were included. To evaluate operative risk, estimated blood loss (EBL), operative time, and length of hospital stay were collected. To evaluate patient-reported outcomes (PROs), Neck Disability Index (NDI) and SF-12 questionnaires (PCS12 and MCS12) were obtained at follow-up. Revision surgery data were also obtained., Results: A total of 168 patients were included and divided into a C7 end-of-fusion cohort (NC7=59) and a T1 end-of-fusion cohort (NT1=109). Multivariate regression analysis adjusting for age, sex, race, surgical approach, and number of levels fused showed that EBL (P=0.12), operative time (P=0.07), and length of hospital stay (P=0.06) are not significantly different in the C7 and T1 end-of-fusion cohorts. Multivariate regression of PROs showed no significant difference in NDI (P=0.70), PCS12 (P=0.23), or MCS12 (P=0.15) between cohorts. Fisher analysis showed significantly higher revision rates in the C7 end-of-fusion cohort (7/59 for C7 vs. 2/109 for T1; odds ratio, 6.4; 95% confidence interval, 1.2-65.1; P=0.01)., Conclusions: Crossing the CTJ in cervical arthrodesis does not increase operative risk as measured by blood loss, operative time, and length of hospital stay. However, it leads to lower revision rates, likely because of the avoidance of ASD, and comparable PROs. Thus, crossing the CTJ may help prevent ASD without negatively affecting operative risk or long-term PROs.

Study Design: Prospective cohort study., Objective: To evaluate whether Patient-Reported Outcomes Measurement Information System (PROMIS) health domains can effectively estimate health utility index values for patients presenting for spine surgery., Summary of Background Data: Stable estimates of health utility are required to determine cost-effectiveness of spine surgery. There are no established methods to estimate health utility using PROMIS., Methods: We enrolled 439 patients with spine disease (mean age, 54 ± 18 yrs) presenting for surgery and assessed their health using the Medical Outcomes Study Short Form-12, version 2 (SF-12v2) and PROMIS domains. Standard health utility values were estimated from the SF-12v2. Participants were randomly assigned to derivation or validation cohort. In the derivation cohort, health utility values were estimated as a function of PROMIS domains using regression models. Model fit statistics determined the most parsimonious health utility estimation equation (HEE). In the validation cohort, values were calculated using the HEE. Estimated health utility values were correlated with SF-12v2-derived health utility values., Results: Mean preoperative health utility was 0.492 ± 0.008 and was similar between the two cohorts. All PROMIS health domains were significantly associated with health utility except Anxiety (P = 0.830) and Sleep Disturbance (P = 0.818). The final HEE was:Health Utility (est) = 0.70742 - 0.00471 × Pain + 0.00647 × Physical function - 0.00316 × Fatigue - 0.00214 × Depression + 0.00317 × Satisfaction with Participation in Social Roles.The estimation model accounted for 74% of observed variation in health utility. In the validation sample, mean health utility was 0.5033 ± 0.1684 and estimated health utility was 0.4966 ± 0.1342 (P = 0.401). These measures were strongly correlated (rho = 0.834)., Conclusion: Our results indicate that PROMIS provides a reasonable estimate of health utility in adults presenting for lumbar or cervical spine surgery., Level of Evidence: 1.

Objective: In this paper, the authors demonstrate to spine surgeons the prevalence and severity of anxiety and depression among patients presenting for surgery and explore the relationships between different legacy and Patient-Reported Outcomes Measurement Information System (PROMIS) screening measures., Methods: A total of 512 adult spine surgery patients at a single institution completed the 7-item Generalized Anxiety Disorder questionnaire (GAD-7), 8-item Patient Health Questionnaire (PHQ-8) depression scale, and PROMIS Anxiety and Depression computer-adaptive tests (CATs) preoperatively. Correlation coefficients were calculated between PROMIS scores and GAD-7 and PHQ-8 scores. Published reference tables were used to determine the presence of anxiety or depression using GAD-7 and PHQ-8. Sensitivity and specificity of published guidance on the PROMIS Anxiety and Depression CATs were compared. Guidance from 3 sources was compared: published GAD-7 and PHQ-8 crosswalk tables, American Psychiatric Association scales, and expert clinical consensus. Receiver operator characteristic curves were used to determine data-driven cut-points for PROMIS Anxiety and Depression. Significance was accepted as p < 0.05., Results: In 512 spine surgery patients, anxiety and depression were prevalent preoperatively (5% with any anxiety, 24% with generalized anxiety screen-positive; and 54% with any depression, 24% with probable major depression). Correlations were moderately strong between PROMIS Anxiety and GAD-7 scores (r = 0.72; p < 0.001) and between PROMIS Depression and PHQ-8 scores (r = 0.74; p < 0.001). The observed correlation of the PROMIS Depression score was greater with the PHQ-8 cognitive/affective score (r = 0.766) than with the somatic score (r = 0.601) (p < 0.001). PROMIS Anxiety and Depression CATs were able to detect the presence of generalized anxiety screen-positive (sensitivity, 86.0%; specificity, 81.6%) and of probable major depression (sensitivity, 82.3%; specificity, 81.4%). Receiver operating characteristic curve analysis demonstrated data-driven cut-points for these groups., Conclusions: PROMIS Anxiety and Depression CATs are reliable tools for identifying generalized anxiety screen-positive spine surgery patients and those with probable major depression.

Study Design: Case report and literature review., Objective: To characterize the rare presentation of myelopathy occurring secondary to alkaptonuria and to evaluate the available evidence regarding its treatment., Summary of Background Data: Alkaptonuria is an autosomal recessive genetic condition with an estimated incidence of 1 in 250,000 to 1 in 1,000,000 people. Mutation of the enzyme homogentisate 1,2-dioxygenase leads to the production of high levels of homogentisic acid, with subsequent deposition in ligaments, cartilage, and menisci. Involvement of the spine is termed "ochronotic spondyloarthropathy," of which myelopathy is an uncommon presentation., Methods: We present the case of a 57-year-old man with alkaptonuria-associated myelopathy, who underwent surgical decompression. Ten additional cases were identified in the literature by a systematic search of PubMed and Google Scholar., Results: In a patient presenting with myelopathy, alkaptonuria may be suspected because of medical history, family history, symptoms (including darkened urine, pigmented ear cartilage, and sclera), or radiographic changes, such as multilevel disc collapse, progressive wafer-like disc calcification, extensive osteophyte formation, and spinal deformity. The diagnosis can be confirmed by urine homogentisic acid testing. Of the 11 patients presented here or identified in the literature, 2 were treated nonoperatively, 8 were treated with decompressive spinal surgery, and treatment of the myelopathy was not discussed for 1 patient. In all cases in which outcomes were reported, substantial improvement in the patient's condition was seen., Conclusion: Alkaptonuria is a rare cause of myelopathy, but one that clinicians should understand. Although no disease-modifying treatment currently exists for alkaptonuria, the use of symptomatic treatments and, particularly, surgical decompression is recommended to address myelopathy if it develops., Level of Evidence: 4.

OBJECTIVEIt is important to identify differences in the treatment of common diseases over time and across geographic regions. Several studies have reported increased use of arthrodesis to treat lumbar spinal stenosis (LSS). The purpose of this study was to investigate geographic variations in the treatment of LSS by US region.METHODSThe authors reviewed inpatient and outpatient medical claims from 2010 to 2014 using the MarketScan Commercial Claims and Encounters database (Truven Health Analytics), which includes data on commercially insured members younger than 65 years. ICD-9 code 724.02 was used to identify patients aged ≥ 40 and < 65 years who underwent surgery for "spinal stenosis of the lumbar region" and for whom LSS was the only principal diagnosis. The primary outcome was the performance of spinal arthrodesis as part of the procedure. Geographic regions were based on patient residence and defined according to the US Census Bureau as the Northeast, Midwest, South, and West.RESULTSRates of arthrodesis, as opposed to decompression alone, varied significantly by region, from 48% in the South, to 42% in the Midwest, 36% in the Northeast, and 31% in the West. After controlling for patient age, sex, and Charlson Comorbidity Index values, the differences remained significant. Compared with patients in the Northeast, those in the South (OR 1.6, 95% CI 1.50-1.75) and Midwest (OR 1.3, 95% CI 1.18-1.41) were significantly more likely to undergo spinal arthrodesis. On multivariate analysis, patients in the West were significantly less likely to have a prolonged hospital stay (> 3 days) than those in the Northeast (OR 0.84, 95% CI 0.75-0.94). Compared with the rate in the Northeast, the rates of discharge to a skilled nursing facility were lower in the South (OR 0.41, 95% CI 0.31-0.55) and West (OR 0.72, 95% CI 0.53-0.98). The 30-day readmission rate was significantly lower in the West (OR 0.81, 95% CI 0.65-0.98) than in the Northeast and similar between the other regions. Mean payments were significantly higher in the Midwest (mean difference $5503, 95% CI $4279-$6762), South (mean difference $6187, 95% CI $5041-$7332), and West (mean difference $7732, 95% CI $6384-$9080) than in the Northeast.CONCLUSIONSThe use of spinal arthrodesis, as well as surgical outcomes and payments for the treatment of LSS, varies significantly by US region. This highlights the importance of developing national recommendations for the treatment of LSS.

Study Design: A prospective cohort study., Objective: The aim of this study was to investigate the ability of Patient-Reported Outcomes Measurement Information System (PROMIS) health domains to discriminate between levels of disease severity and to determine the concurrent validity and responsiveness of PROMIS relative to "legacy" measures., Summary of Background Data: PROMIS may measure recovery after lumbar spine surgery. Concurrent validity and responsiveness have not been compared with legacy measures in this population., Methods: We included 231 adults undergoing surgery for lumbar degenerative disease. Discriminant ability of PROMIS was estimated for adjacent categories of disease severity using the Oswestry Disability Index (ODI). Concurrent validity was determined through correlation between preoperative legacy measures and PROMIS. Responsiveness was estimated using distribution-based and anchor-based criteria (change from preoperatively to within 3 months postoperatively) anchored to treatment expectations (North American Spine Society Patient Satisfaction Index) to determine minimal important differences (MIDs). Significance was accepted at P < 0.05., Results: PROMIS discriminated between disease severity levels, with mean differences between adjacent categories of 3 to 8 points. There were strong to very strong correlations between Patient Health Questionnaire-8, Generalized Anxiety Disorder-7, and PROMIS anxiety, depression, fatigue, and sleep disturbance; between ODI and PROMIS fatigue, pain, and physical function; between the 12-Item Short-Form Health Survey physical component and PROMIS pain and physical function; and between the Brief Pain Inventory (BPI) pain interference and PROMIS depression and pain. BPI back pain and leg pain intensity showed weak or no correlation with PROMIS. Distribution-based MIDs ranged from 3.0 to 3.5 points. After incorporating longitudinal anchor-based estimates, final PROMIS MID estimates were anxiety, -4.4; depression, -6.0; fatigue, -5.3; pain, -5.4; physical function, 5.2; satisfaction with participation in social roles, 6.0; and sleep disturbance, -6.5., Conclusion: PROMIS discriminated between disease severity levels, demonstrated good concurrent validity, and was responsive to changes after lumbar spine surgery., Level of Evidence: 2.

OBJECTIVE Recommendations for the surgical treatment of isolated lumbar spinal stenosis (LSS) (i.e., in the absence of concomitant scoliosis or spondylolisthesis) are unclear. The aims of this study were to investigate trends in the surgical treatment of isolated LSS in US adults and determine implications for outcomes. METHODS The authors analyzed inpatient and outpatient claims from the Truven Health Analytics MarketScan Commercial Claims and Encounters Database for 20,279 patients aged 40-64 years who underwent surgery for LSS between 2010 and 2014. Only patients with continuous 12-month insurance coverage after surgery were included. The rates of decompression with arthrodesis versus decompression only and of simple (1- or 2-level, single-approach) versus complex (> 2-level or combined-approach) arthrodesis were analyzed by year and geographic region. These trends were further analyzed with respect to complications, length of hospital stay, payments made to the hospital, and patient discharge status. Statistical significance was set at p < 0.05. RESULTS The proportion of patients who underwent decompression with arthrodesis compared with decompression only increased significantly and linearly from 2010 to 2014 (OR 1.08; 95% CI 1.06-1.10). Arthrodesis was more likely to be complex rather than simple with each subsequent year (OR 1.4; 95% CI 1.33-1.49). This trend was accompanied by an increased likelihood of postoperative complications (OR 1.11; 95% CI 1.02-1.21), higher costs (payments increased by a mean of US$1633 per year; 95% CI 1327-1939), and greater likelihood of being discharged to a skilled nursing facility as opposed to home (OR 1.11; 95% CI 1.03-1.20). The South and Midwest regions of the US had the highest proportions of patients undergoing arthrodesis (48% and 42%, respectively). The mean length of hospital stay did not change significantly (p = 0.324). CONCLUSIONS From 2010 to 2014, the proportion of adults undergoing decompression with arthrodesis versus decompression only for the treatment of LSS increased, especially in the South and Midwest regions of the US. A greater proportion of these fusions were complex and were associated with more complications, higher costs, and a greater likelihood of being discharged to a skilled nursing facility.

Study Design: Prospective cohort., Objective: Determine A) between-patient variability in patient-reported outcomes (PROs) at four postoperative time points; B) within-patient correlation of 1-year PROs with PROs at three earlier time points; and C) ability of early PROs to predict 1-year PROs after lumbar laminectomy with arthrodesis., Summary of Background Data: It is unclear whether early PROs can help identify patients at risk for poor health outcomes., Methods: Between 2015 and 2016, we assessed pre- and postoperative back pain, leg pain, disability, physical health, and mental health in 146 patients. We examined PRO variability between patients and correlations within patients during the first postoperative year. For early (≤3-mo) and 1-year PROs, we examined concordance between experiencing a minimal important difference (MID) early and at 1 year and odds of experiencing a 1-year MID given early absence of a MID., Results: Postoperatively, we found increasing between-patient variability of PROs. For individual patients, we found moderate to strong between-assessment correlations (intraclass correlations) between repeated PROs (back pain, 0.47; leg pain, 0.51; disability, 0.47; physical health, 0.63; mental health, 0.53). Early MIDs were experienced for back pain (57%), leg pain (52%), physical health (38%), disability (34%), and mental health (16%). Concordance was moderate for leg pain (0.48), mental health (0.46), disability (0.38), back pain (0.36), and physical health (0.25). In patients without an early MID, odds of experiencing a MID at 1 year were low for physical health (odds ratio [OR] = 0.33), back pain (OR = 0.30), leg pain (OR = 0.14), and disability (OR = 0.11) but not mental health (OR = 0.50)., Conclusion: Although postoperative recovery is variable, early PROs can identify patients at risk for poor 1-year outcomes and may help tailor care during the first year after lumbar laminectomy with arthrodesis., Level of Evidence: 2.

Degenerative disc disease (DDD) is associated with intervertebral disc degeneration of spinal instability. Here, we report that the cilia of nucleus pulposus (NP) cells mediate mechanotransduction to maintain anabolic activity in the discs. We found that mechanical stress promotes transport of parathyroid hormone 1 receptor (PTH1R) to the cilia and enhances parathyroid hormone (PTH) signaling in NP cells. PTH induces transcription of integrin α v β 6 to activate the transforming growth factor (TGF)-β-connective tissue growth factor (CCN2)-matrix proteins signaling cascade. Intermittent injection of PTH (iPTH) effectively attenuates disc degeneration of aged mice by direct signaling through NP cells, specifically improving intervertebral disc height and volume by increasing levels of TGF-β activity, CCN2, and aggrecan. PTH1R is expressed in both mouse and human NP cells. Importantly, knockout PTH1R or cilia in the NP cells results in significant disc degeneration and blunts the effect of PTH on attenuation of aged discs. Thus, mechanical stress-induced transport of PTH1R to the cilia enhances PTH signaling, which helps maintain intervertebral disc homeostasis, particularly during aging, indicating therapeutic potential of iPTH for DDD., Competing Interests: The authors declare no competing interests.

Background: Spine surgery outcomes are variable. Patients who participate in and take responsibility for their recovery have improved health outcomes. Interventions to increase patient involvement in their care may improve health outcomes after a surgical procedure. We conducted a prospective interventional trial to compare the effectiveness of health behavior change counseling with usual care to improve health outcomes after lumbar spine surgical procedures., Methods: In this study, 122 patients with lumbar spinal stenosis undergoing a decompression surgical procedure from December 2009 through August 2012 were enrolled. Participants were assigned, according to enrollment date, to health behavior change counseling or usual care. Health behavior change counseling is a brief, telephone-based intervention intended to increase rehabilitation engagement through motivational interviewing strategies that elicit and strengthen motivation for change. Health behavior change counseling was designed to identify patients with low patient activation, to maximize postoperative rehabilitation engagement, to decrease pain and disability, and to improve functional recovery. Participants were assessed before the surgical procedure and for 3 years after the surgical procedure for pain intensity (Brief Pain Inventory), disability (Oswestry Disability Index), and physical health (12-Item Short-Form Health Survey, version 2). Differences in changes in health outcomes after the surgical procedure were compared between the health behavior change counseling group and the usual care group., Results: By 12 months, health behavior change counseling participants reported significantly greater reductions in pain intensity (p = 0.008) and disability (p = 0.028) and significantly greater improvement in physical health compared with usual care participants (p = 0.025). These differences were attenuated by 24 and 36 months after the surgical procedure. Early improvements in health outcomes were mediated by improvements in physical therapist-rated engagement and self-reported attendance at physical therapy sessions in the health behavior change counseling group., Conclusions: Health behavior change counseling improved health outcomes during the first 12 months after the surgical procedure through changes in rehabilitation engagement. Wider use of health behavior change counseling may lead to improved outcomes not only after lumbar spine surgery but also in other conditions for which rehabilitation is key to recovery., Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Study Design: Prospective cohort study., Objective: The aim of this study was to determine the validity and responsiveness of Patient-Reported Outcomes Measurement Information System (PROMIS) health domains., Summary of Background Data: PROMIS health domains (anxiety, depression, fatigue, pain, physical function, satisfaction with participation in social roles, sleep disturbance) may measure quality of care and determine minimal important differences (MIDs) after spine surgery. We examined concurrent validity of PROMIS domains before and PROMIS domain MIDs after anterior cervical spine surgery., Methods: We included 148 adults undergoing cervical spine surgery from February 2015 through June 2016. We determined concurrent validity by correlations of preoperative PROMIS domains with legacy measures and responsiveness of PROMIS domains using distribution-based and anchor-based criteria (preoperative to postoperative change, within 6 months) anchored to treatment expectations (assessed using North American Spine Society Patient Satisfaction Index criteria). Statistical significance was accepted as P < 0.05., Results: All PROMIS domains showed moderate to strong correlations with Neck Disability Index, Short-Form Health Survey, version 2 (SF-12v2), and Brief Pain Inventory pain interference and weak correlations with intensity of arm/neck pain (except between PROMIS pain and neck pain [r = 0.45, P < 0.001] and PROMIS physical function and SF-12v2 physical [r = -0.14, P = 0.138] and mental [r = 0.39, P < 0.001] components). PROMIS domains were well correlated with Generalized Anxiety Disorder-7 and Patient Health Questionnaire-8 except PROMIS physical function (r = -0.29, P = 0.002). Distribution-based PROMIS MID estimates ranged from 2.3 to 3.9 points. Incorporating cross-sectional and longitudinal anchor-based criteria, final PROMIS MID estimates were as follows: anxiety, -5.7; depression, -4.6, fatigue, -5.8; pain, -5.2; physical function, 4.5; satisfaction with participation in social roles, 4.4; and sleep disturbance, -7.4., Conclusion: PROMIS domains are a valid assessment of health in this population and were responsive to postoperative improvements in symptoms and quality of life., Level of Evidence: 2.

Background: Delirium is common after surgery, although the aetiology is poorly defined. Brain-derived neurotrophic factor (BDNF) is a neurotrophin important in neurotransmission and neuroplasticity. Decreased levels of BDNF have been associated with poor cognitive outcomes, but few studies have characterized the role of BDNF perioperatively. We hypothesized that intraoperative decreases in BDNF levels are associated with postoperative delirium., Methods: Patients undergoing spine surgery were enrolled in a prospective cohort study. Plasma BDNF was collected at baseline and at least hourly intraoperatively. Delirium was assessed using rigorous methods, including the Confusion Assessment Method (CAM) and CAM for the intensive care unit. Associations of changes in BDNF and delirium were examined using regression models., Results: Postoperative delirium developed in 32 of 77 (42%) patients. The median baseline BDNF level was 7.6 ng ml -1 [interquartile range (IQR) 3.0-11.2] and generally declined intraoperatively [median decline 61% (IQR 31-80)]. There was no difference in baseline BDNF levels by delirium status. However, the percent decline in BDNF was greater in patients who developed delirium [median 74% (IQR 51-82)] vs in those who did not develop delirium [median 50% (IQR 14-79); P =0.03]. Each 1% decline in BDNF was associated with increased odds of delirium in unadjusted {odds ratio [OR] 1.02 [95% confidence interval (CI) 1.00-1.04]; P =0.01}, multivariable-adjusted [OR 1.02 (95% CI 1.00-1.03); P =0.03], and propensity score-adjusted models [OR 1.02 (95% CI 1.00-1.04); P =0.03]., Conclusions: We observed an association between intraoperative decline in plasma BDNF and delirium. These preliminary results need to be confirmed but suggest that plasma BDNF levels may be a biomarker for postoperative delirium., (© The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com)

Intervertebral disc (IVD) degeneration is the leading cause of disability with no disease-modifying treatment. IVD degeneration is associated with instable mechanical loading in the spine, but little is known about how mechanical stress regulates nucleus notochordal (NC) cells to maintain IVD homeostasis. Here we report that mechanical stress can result in excessive integrin α v β 6 -mediated activation of transforming growth factor beta (TGFβ), decreased NC cell vacuoles, and increased matrix proteoglycan production, and results in degenerative disc disease (DDD). Knockout of TGFβ type II receptor (TβRII) or integrin α v in the NC cells inhibited functional activity of postnatal NC cells and also resulted in DDD under mechanical loading. Administration of RGD peptide, TGFβ, and α v β 6 -neutralizing antibodies attenuated IVD degeneration. Thus, integrin-mediated activation of TGFβ plays a critical role in mechanical signaling transduction to regulate IVD cell function and homeostasis. Manipulation of this signaling pathway may be a potential therapeutic target to modify DDD., Competing Interests: The authors declare no conflict of interest.

Purpose: Diffusion tensor imaging (DTI) metrics of the cervical spinal cord in patients with cervical spondylotic myelopathy (CSM) were compared to those measured in healthy volunteers, using tract-specific region of interests (ROIs) across all cervical intervertebral disc levels., Methods: Magnetic resonance (MR) imaging of the cervical spinal cord was performed in four patients with CSM and in five healthy volunteers on a 3-T MR scanner. Region-specific fractional anisotropy (FA) and mean diffusivity (MD) were calculated on axial imaging with ROI placement in the anterior, lateral, and posterior regions of the spinal cord. FA and MD were also calculated on sagittal acquisitions. Nonparametric statistical tests were used to compare controls and patients before and after surgery., Results: FA values were significantly lower (p = 0.050) and MD values were significantly higher (p = 0.014) in CSM patients measured at level of maximal compression before surgery than in healthy controls in lateral and posterior ROIs, respectively. In posterior ROIs, MD values were significantly higher in patients before surgery compared to controls at all levels except C7-T1., Conclusion: Patients with CSM may demonstrate region-specific changes in DTI metrics when compared to healthy controls. Changes in DTI metrics may also occur at levels remote from site of compression.

Objectives: To characterize the incidence, risk factors, and consequences of delirium in older adults undergoing spine surgery., Design: Prospective observational study., Setting: Academic medical center., Participants: Individuals aged 70 and older undergoing spine surgery (N = 89)., Measurements: Postoperative delirium and delirium severity were assessed using validated methods, including the Confusion Assessment Method (CAM), CAM for the Intensive Care Unit, Delirium Rating Scale-Revised-98, and chart review. Hospital-based outcomes were obtained from the medical record and hospital charges from data reported to the state., Results: Thirty-six participants (40.5%) developed delirium after spine surgery, with 17 (47.2%) having purely hypoactive features. Independent predictors of delirium were lower baseline cognition, higher average baseline pain, more intravenous fluid administered, and baseline antidepressant medication. In adjusted models, the development of delirium was independently associated with higher quintile of length of stay (odds ratio (OR) = 3.66, 95% confidence interval (CI) = 1.48-9.04, P = .005), higher quintile of hospital charges (OR = 3.49, 95% CI = 1.35-9.00, P = .01), and lower odds of discharge to home (OR = 0.22, 95% CI = 0.07-0.69, P = .009). Severity of delirium was associated with higher quintile of hospital charges and lower odds of discharge to home., Conclusion: Delirium is common after spine surgery in older adults, and baseline pain is an independent risk factor. Delirium is associated with longer stay, higher charges, and lower odds of discharge to home. Thus, prevention of delirium after spine surgery may be an important quality improvement goal., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Background: The clinical relevance of chronic exposure to selective serotonin reuptake inhibitors (SSRIs) to transfusion in surgical patients is unclear., Methods: We conducted a prospective cohort study involving patients undergoing cardiac, vascular, spinal, and intracranial surgery at 2 academic medical centers. Medication use, demographics, comorbidities, and laboratory values were determined at baseline by patient interview and review of medical records. The primary outcome was transfusion of any hemostatic allogeneic blood product (i.e., fresh frozen plasma, platelets, and/or cryoprecipitate) through postoperative day 2., Results: The study sample consisted of 767 patients; 364 patients (47.5%) underwent cardiac surgery and the remainder underwent noncardiac surgery. Eighty-eight patients (11.5%) used SSRIs preoperatively. Among cardiac patients, the absolute number of allogeneic transfusions was higher for SSRI users than nonusers (2 [0-6] vs 0 [0-2], median [25%-75%], respectively, P = 0.008), and a similar trend was observed for noncardiac surgery. After adjusting for covariates using ordinal logistic regression, preoperative SSRI use was associated with an approximately 2-fold (odds ratio, 2.2; 95% confidence interval, 1.2-3.98) increase in odds of exposure to allogeneic hemostatic blood products; similar results were observed using propensity score adjustment (odds ratio, 1.85; 95% confidence interval, 1.11-3.07). A significant interaction between SSRI use and surgery type, age, sex, or concurrent antiplatelet therapy was not found; however, heterogeneity in magnitude of effect could not be excluded., Conclusions: Preoperative use of SSRIs is associated with increased exposure to allogeneic hemostatic blood products in surgical patients at high risk for perioperative bleeding. Determining whether perioperative continuation or withdrawal of SSRIs produces a net clinical benefit requires randomized controlled trials.

Narrowed intervertebral disc (IVD) space is a characteristic of IVD degeneration. EP sclerosis is associated with IVD, however the pathogenesis of EP hypertrophy is poorly understood. Here, we employed two spine instability mouse models to investigate temporal and spatial EP changes associated with IVD volume, considering them as a functional unit. We found that aberrant mechanical loading leads to accelerated ossification and hypertrophy of EP, decreased IVD volume and increased activation of TGFβ. Overexpression of active TGFβ in CED mice showed a similar phenotype of spine instability model. Administration of TGFβ Receptor I inhibitor attenuates pathologic changes of EP and prevents IVD narrowing. The aberrant activation of TGFβ resulting in EPs hypertrophy-induced IVD space narrowing provides a pharmacologic target that could have therapeutic potential to delay DDD.