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To develop age- and BMI-adjusted alignment targets to improve patient-specific management and operative treatment outcomes.Retrospective review of a single-center stereographic database. ASD patients receiving operative or non-operative treatment, ≥ 18y/o with complete baseline (BL) ODI scores and radiographic parameters (PT, SVA, PILL, TPA) were included. Patients were stratified by age consistent with US-Normative values (norms) of SF-36( 35, 35-55, 45-54, 55-64, 65-74, ≥ 75y/o), and dichotomized by BMI (Non-Obese 30; Obese ≥ 30). Linear regression analysis established normative age- and BMI-specific radiographic thresholds, utilizing previously published age-specific US-Normative ODI values converted from SF-36 PCS (Lafage et al.), in conjunction with BL age and BMI means.486 patients were included (Age: 52.5, Gender: 68.7%F, mean BMI: 26.2, mean ODI: 32.7), 135 of which were obese. Linear regression analysis developed age- and BMI-specific alignment thresholds, indicating PT, SVA, PILL, and TPA to increase with both increased age and increased BMI (all R 0.5, p 0.001). For non-obese patients, PT, SVA, PILL, and TPA ranged from 10.0, - 25.8, - 9.0, 3.1 in patients 35y/o to 27.8, 53.4, 17.7, 25.8 in patients ≥ 75 y/o. Obese patients' PT, SVA, PILL, and TPA ranged from 10.5, - 7.6, - 7.1, 5.8 in patients 35 y/o to 28.3, 67.0, 19.15, 27.7 in patients ≥ 75y/o. Normative SVA values in obese patients were consistently ≥ 10 mm greater compared to non-obese values, at all ages.Significant associations exist between age, BMI, and sagittal alignment. While BMI influenced age-adjusted alignment norms for PT, SVA, PILL, and TPA at all ages, obesity most greatly influenced SVA, with normative values similar to non-obese patients who were 10 years older. Age-adjusted alignment thresholds should take BMI into account, calling for less rigorous alignment objectives in older and obese patients.

OBJECTIVE: To assess whether surgical cervical deformity (CD) patients meet spinopelvic age-adjusted alignment targets, reciprocal, and lower limb compensation changes. STUDY DESIGN: Retrospective review. METHODS: CD was defined as C2-C7 lordosis >10°, cervical sagittal vertical angle (cSVA) >4 cm, or T1 slope minus cervical lordosis (TS-CL) >20°. Inclusion criteria were age >18 years and undergoing surgical correction with complete baseline and postoperative imaging. Published formulas were used to create age-adjusted alignment target for pelvic tilt (PT), pelvic incidence and lumbar lordosis (PI-LL), sagittal vertical angle (SVA), and lumbar lordosis and thoracic kyphosis (LL-TK). Actual alignment was compared with age-adjusted ideal values. Patients who matched ±10-year thresholds for age-adjusted targets were compared with unmatched cases (under- or overcorrected). RESULTS: A total of 120 CD patients were included (mean age, 55.1 years; 48.4% women; body mass index, 28.8 kg/m(2)). For PT, only 24.4% of patients matched age-adjusted alignment, 51.1% overcorrected for PT, and 24.4% undercorrected. For PI-LL, only 27.6% of CD patients matched age-adjusted targets, with 49.4% overcorrected and 23% undercorrected postoperatively. Forty percent of patients matched age-adjusted target for SVA, 41.3% overcorrected, and 18.8% undercorrected. CD patients who had worsened in TS-CL or cSVA postoperatively displayed increased TK (−41.1° to −45.3°, P = 1.06). With lower extremity compensation, CD patients decreased in ankle flexion angle postoperatively (6.1°–5.5°, P = 0.036) and trended toward smaller sacrofemoral angle (199.6–195.6 mm, P = 0.286) and knee flexion (2.6° to −1.1°, P = 0.269). CONCLUSIONS: In response to worsening CD postoperatively, patients increased in TK and recruited less lower limb compensation. Almost 75% of CD patients did not meet previously established spinopelvic alignment goals, of whom a subset of patients were actually made worse off in these parameters following surgery. This finding raises the question of whether we should be looking at the entire spine when treating CD. LEVEL OF EVIDENCE: 3.

BACKGROUND: More sophisticated surgical techniques for correcting adult spinal deformity (ASD) have increased operative times, adding to physiologic stress on patients and increased complication incidence. This study aims to determine factors associated with operative time using a statistical learning algorithm. METHODS: Retrospective review of a prospective multicenter database containing 837 patients undergoing long spinal fusions for ASD. Conditional inference decision trees identified factors associated with skin-to-skin operative time and cutoff points at which factors have a global effect. A conditional variable-importance table was constructed based on a nonreplacement sampling set of 2000 conditional inference trees. Means comparison for the top 15 variables at their respective significant cutoffs indicated effect sizes. RESULTS: Included: 544 surgical ASD patients (mean age: 58.0 years; fusion length 11.3 levels; operative time: 378 minutes). The strongest predictor for operative time was institution/surgeon. Center/surgeons, grouped by decision tree hierarchy, a and b were, on average, 2 hours faster than center/surgeons c-f, who were 43 minutes faster than centers g-j, all P < 0.001. The next most important predictors were, in order, approach (combined vs posterior increases time by 139 minutes, P < 0.001), levels fused (

Hospital-acquired conditions (HACs) have been the focus of recent initiatives by the Centers for Medicare and Medicaid Services in an effort to improve patient safety and outcomes. Spine surgery can be complex and may carry significant comorbidity burden, including so called "never events." The objective was to determine the rates of common HACs that occur within 30-days post-operatively for elective spine surgeries and compare them to other common surgical procedures. Patients:18 y/o undergoing elective spine surgery were identified in the American College of Surgeons' NSQIP database from 2005 to 2013. Patients were stratified by whether they experienced1 HAC, then compared to those undergoing other procedures including bariatric surgery, THA and TKA. Of the 90,551 spine surgery patients, 3021 (3.3%) developed at least one HAC. SSI was the most common (1.4%), followed by UTI (1.3%), and VTE (0.8%). Rates of HACs in spine surgery were significantly higher than other elective procedures including bariatric surgery (2.8%) and THA (2.8%) (both p 0.001). Spine surgery and TKA patients had similar rates of HACs(3.3% vs 3.4%, p = 0.287), though spine patients experienced higher rates of SSI (1.4%vs0.8%, p 0.001) and UTI (1.3%vs1.1%, p 0.001) but lower rates of VTE (0.8%vs1.6%, p 0.001). Spine surgery patients had lower rates of HACs overall (3.3%vs5.9%) when compared to cardiothoracic surgery patients (p 0.001). When compared to other surgery types, spine procedures were associated with higher HACs than bariatric surgery patients and knee and hip arthroplasties overall but lower HAC rates than patients undergoing cardiothoracic surgery.

The objectives of this study were to characterize the risk of death (1) from the primary cancer vs competing cause of death; and (2) from various causes of death vs the general poplation. The relative risk of death after a pediatric cancer diagnosis versus the general population and the risk of death from a primary cancer diagnosis versus competing causes of death.This retrospective, population-based study used the Surveillance, Epidemiology, and End Results database (1980-2015) and included patients aged 0 to 19 years at the time of diagnosis. Observed deaths were calculated; the risk of death versus the general population was assessed with standardized mortality ratios (SMRs). Competing risk models for the cause of death were performed.There were 58,356 patients who were diagnosed, and the mortality rate was 22.8%. To assess causes of death, 6996 patients who died during the study period were included (45,580 total person-years at risk): 5128 (73%) died of their primary cancer, and 1868 (27%) died of a competing cause. Among all patients, the rate of death from the index cancer was higher than the rate of death from another cause within the first 5 years after diagnosis. The risk of death from a nonprimary cancer began to supersede the rate of death from the primary cancer 10 years after diagnosis for patients with germ cell tumors, lymphomas, and sarcomas. SMRs for the primary cancer were highest within the first 5 years after diagnosis for all cancers (SMRs, 100-50,000; P .0001). The risk of death from competing causes (heart disease, suicide, and sepsis) was elevated (SMR,100; P .001). The risk of dying of heart disease was high, especially for patients with astrocytomas (SMR, 47.84; 95% confidence interval [CI], 27.87-76.59) and neuroblastomas (SMR, 98.59; 95% CI, 47.28-181.32). The risk of dying of suicide was high in most patients, particularly for those with osteosarcomas (SMR, 111.40; 95% CI, 2.82-620.69), Hodgkin lymphomas (SMR, 62.35; 95% CI, 34.89-102.83), and gonadal germ cell tumors (SMR, 28.97; 95% CI, 12.51-57.09).The cause of death for patients with gonadal germ cell tumors, lymphomas, and sarcomas is more commonly a secondary cancer or noncancerous cause than the primary disease; their risk of death from competing causes (heart disease, suicide, and sepsis) rises throughout life.

INTRODUCTION Obesity is associated with acceleration of musculoskeletal degenerative diseases and functional impairment secondary to spinal disorders. Bariatric surgery (BS) is an increasingly common treatment for severe obesity but can affect bone and mineral metabolism. The effect of BS on degenerative spinal disorders is yet to be fully described. The aim of our study was to analyze changes in bariatric patients' risk for spinal degenerative diseases and spinal surgery. METHODS Retrospective analysis of the prospectively collected New York State Inpatient Database (NYSID) years (2004-2013) using patient linkage codes. The incidence of degenerative spinal diagnoses and spinal surgery was queried using International Classification of Diseases, Ninth Revision (ICD)-9 codes for morbidly obese patients (ICD-9 278.01) with and without a history of BS. The incidence of degenerative spinal diagnoses and spinal surgery was determined using χ tests for independence. Logistic testing controlled for age, sex, and comorbidity burden. RESULTS A total of 18,176 patients were identified in the NYSID database with a history of BS and 146,252 patients were identified as morbidly obese without a history of BS. BS patients have a significantly higher rate of spinal diagnoses than morbidly obese patients without BS (19.3% vs. 8.1%, P

It’s increasingly common for surgeons to operate on more challenging cases and higher risk patients, resulting in longer op-time and inpatient LOS. Factors predicting extended op-time and LOS for cervical deformity (CD) patients are understudied. This study identified predictors of extended op-time and length of stay (LOS) after CD-corrective surgery. CD patients with baseline (BL) radiographic data were included. Patients were stratified by extended LOS (ELOS; >75th percentile) and normal LOS (N-LOS; 12 h. A Conditional Variable Importance Table used non-replacement sampling set of Conditional Inference trees to identify influential factors. Mean comparison tests compared LOS and op-time for top factors. 142 surgical CD patients (61 yrs, 62%F, 8.2 levels fused). Op-time and LOS were 358 min and 7.2 days; 30% of patients experienced E-LOS (14 ± 13 days). Overlapping predictors of E-LOS and op-time included levels fused (>7 increased LOS 2.7 days; >5 increased op-time 96 min, P 38 kg/m2 increased LOS 8.1 days; >39 kg/m2 increased op-time 17 min), and osteotomy (LOS 2.0 days, op-time 62 min, P 42 mm increased LOS; >50 mm increased op-time, P @−0.9° increased LOS, >0.3° increased op-time, P

Introduction: Lung metastasis is usually associated with poor outcomes in cancer patients. This study was performed to characterize and analyze the population of patients with de novo (synchronous) lung metastases using the Surveillance, Epidemiology and End Results (SEER) database.Materials and Methods: Baseline characteristics of lung metastasis patients were obtained from SEER case listings. Incidence rates and counts of synchronous lung metastasis were also obtained using the SEER*Stat software. Survival outcomes were analyzed using univariate and multivariable Cox regressions, controlling for confounders. An alpha threshold of 0.05 was used for statistical significance and p-values were subject to correction for multiple comparisons.Results: The age-adjusted incidence rate of synchronous lung metastasis was 17.92 per 100,000 between 2010 and 2015. Synchronous lung metastases most commonly arose from primary lung cancers, colorectal cancers, kidney cancers, pancreatic cancers and breast cancers. During this time period, 4% of all cancer cases presented with synchronous lung metastasis. The percentage of patients presenting with synchronous lung metastasis ranged from 0.5% of all prostate cancers to 13% of all primary lung cancers. The percentage of all cancer cases presenting with synchronous lung metastasis increased over time. De novo metastatic patients with lung metastases had worse overall survival [hazard ratio = 1.22 (1.21–1.23), p < 0.001] compared to those with only extrapulmonary metastases, controlling for potential confounders.Conclusions: Synchronous lung metastasis occurs frequently and is an independent predictors of poor patient outcomes. As treatment for lung metastases becomes more complicated, patients with synchronous lung metastasis represent a high-risk population.

STUDY DESIGN Single institution retrospective clinical review. OBJECTIVE To investigate the relationship between levels fused and clinical outcomes in patients undergoing open and minimally invasive surgical (MIS) lumbar fusion. SUMMARY OF BACKGROUND DATA Minimally invasive spinal fusion aims to reduce the morbidity associated with conventional open surgery. As multilevel arthrodesis procedures are increasingly performed using MIS techniques, it is necessary to weigh the risks and benefits of multilevel MIS lumbar fusion as a function of fusion length. METHODS Patients undergoing

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

Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database years 2010 to 2015.Investigate which short-term outcomes differ for cervical laminoplasty and laminectomy and fusion surgeries.Conflicting reports exist in spine literature regarding short-term outcomes following cervical laminoplasty and posterior laminectomy and fusion. The objective of this study was to compare the 30-day outcomes for these two treatment groups for multilevel cervical pathology.Patients who underwent cervical laminoplasty or posterior laminectomy and fusion were identified in National Surgical Quality Improvement Program (NSQIP) based on Current Procedural Terminology (CPT) code: laminoplasty 63,050 and 63,051, posterior cervical laminectomy 63,015 and 63,045, and instrumentation 22,842. Propensity-adjusted multivariate regressions assessed differences in postoperative length of stay, adverse events, discharge disposition, and readmission.Three thousand seven hundred ninety-six patients were included: 2397 (63%) underwent cervical laminectomy and fusion and 1399 (37%) underwent cervical laminoplasty. Both groups were similar in age, sex, body mass index (BMI), American Society of Anesthesiologist Classification (ASA), Charleston Comorbidity Index (CCI), and had similar rates of malnutrition, chronic kidney disease, diabetes, chronic obstructive pulmonary disease, and history for steroid use. Age more than 70 and age less than 50 were not associated with one treatment group over the other (P 0.05). Compared with laminoplasty patients, laminectomy and fusion patients had increased lengths of stay (LOS) (4.5 vs. 3.7 d, P 0.01) and increased rates of adverse events (41.7% vs. 35.9%, P 0.01), discharge to rehab (16.4% vs. 8.6%, P 0.01), and skilled nursing facilities (12.2% vs. 9.7%, P = 0.02), and readmission (6.2% vs. 4.5%, P = 0.05). Both groups experienced similar rates of death, pulmonary embolus, deep vein thrombosis, deep and superficial surgical site infection, and reoperation (P 0.05 for all).Posterior cervical laminectomy and fusion patients were found to have increased LOS, readmissions, and complications despite having similar pre-op demographics and comorbidities. Patients and surgeons should consider these risks when considering surgical treatment for cervical pathology.3.

Background Congenital abnormalities when present, according to VACTERL theory, occur nonrandomly with other congenital anomalies. This study estimates the prevalence of congenital spinal anomalies, and their concurrence with other systemic anomalies. Methods A retrospective cohort analysis on Health care Cost and Utilization Project's Kids Inpatient Database (KID), years 2000, 2003, 2006, 2009 was performed. ICD-9 coding identified congenital anomalies of the spine and other body systems. Outcome measures Overall incidence of congenital spinal abnormalities in pediatric patients, and the concurrence of spinal anomaly diagnoses with other organ system anomalies. Frequencies of congenital spine anomalies were estimated using KID hospital-and-year-adjusted weights. Poisson distribution in contingency tables tabulated concurrence of other congenital anomalies, grouped by body system. Results Of 12,039,432 patients, rates per 100,000 cases were: 9.1 hemivertebra, 4.3 Klippel-Fiel, 56.3 Chiari malformation, 52.6 tethered cord, 83.4 spina bifida, 1.2 absence of vertebra, and 6.2 diastematomyelia. Diastematomyelia had the highest concurrence of other anomalies: 70.1% of diastematomyelia patients had at least one other congenital anomaly. Next, 63.2% of hemivertebra, and 35.2% of Klippel-Fiel patients had concurrent anomalies. Of the other systems deformities cooccuring, cardiac system had the highest concurrent incidence (6.5% overall). In light of VACTERL's definition of a patient being diagnosed with at least 3 VACTERL anomalies, hemivertebra patients had the highest cooccurrence of ≥3 anomalies (31.3%). With detailed analysis of hemivertebra patients, secundum ASD (14.49%), atresia of large intestine (10.2%), renal agenesis (7.43%) frequently cooccured. Conclusions Congenital abnormalities of the spine are associated with serious systemic anomalies that may have delayed presentations. These patients continue to be at a very high, and maybe higher than previously thought, risk for comorbidities that can cause devastating perioperative complications if not detected preoperatively, and full MRI workups should be considered in all patients with spinal abnormalities. Level of evidence Level III.

BACKGROUND Congenital scoliosis (CS) is associated with more rigid, complex deformities relative to adolescent idiopathic scoliosis (AIS) which theoretically increases surgical complications. Despite extensive literature studying AIS patients, few studies have been performed on CS patients. The purpose of this study was to evaluate complications associated with spinal fusions for CS and AIS. METHODS A retrospective review of the Kid's Inpatient Database (KID) years 2000 to 2009 was performed. Inclusion: patients under 20 years with ICD-9 diagnosis codes for idiopathic scoliosis (IS-without concomitant congenital anomalies) and CS, undergoing spinal fusion from the KID years 2000 to 2009. Two analyses were performed according to age below 10 years and 10 years and above. Univariate analysis described differences in demographics, comorbidities, intraoperative complications, and clinical values between groups. Binary logistic regression controlling for age, sex, race, and invasiveness predicted complications risk in CS (odds ratios; 95% confidence interval). RESULTS In total, 25,131 patients included (IS, n=22443; CS, n=2688). For patients under age 10, CS patients underwent 1 level shorter fusions (P

Study Design: Retrospective cohort study of prospective patients undergoing minimally invasive lumbar fusion at a single academic institution. Objective: To assess differences in perioperative outcomes between primary and revision MIS (minimally invasive surgical) lumbar interbody fusion patients and compare with those undergoing corresponding open procedures. Methods: Patients ≥18 years old undergoing lumbar interbody fusion were grouped by surgical technique: MIS or open. Patients within each group were propensity score matched for comorbidities and levels fused. Patient demographics, surgical factors, and perioperative complication incidences were compared between primary and revision cases using means comparison tests, as appropriate. Results: Of the 214 lumbar interbody fusion patients included after propensity score matching, 44 (21%) cases were MIS, and 170 (79%) were open. For MIS patients, there were no significant differences between primary and revision cases in estimated blood loss (EBL; 344 vs 299 cm3, P = .682); however, primary cases had longer operative times (301 vs 246 minutes, P = .029). There were no differences in length of stay (LOS), intensive care unit LOS, readmission, and intraoperative or postoperative complications (all P > .05). For open patients, there were no differences between primary and revision cases in EBL ( P > .05), although revisions had longer operative times (331 vs 278 minutes, P = .018) and more postoperative complications (61.7% vs 23.8%, P < .001). MIS revision procedures were shorter than open revisions (182 vs 213 minutes, P = .197) with significantly less EBL (294 vs 965 cm3, P < .001), shorter inpatient and intensive care unit LOS, and fewer postoperative complications (all P < .05). Conclusions: Clinical outcomes of revision MIS lumbar interbody fusion were similar to those of primary surgery. Additionally, MIS techniques were associated with less EBL, shorter LOS, and fewer perioperative complications than corresponding open revisions.

The postoperative recovery patterns of cervical deformity patients, thoracolumbar deformity patients, and patients with combined cervical and thoracolumbar deformities, all relative to one another, is not well understood. Clear objective benchmarks are needed to quantitatively define a "good" versus a "bad" postoperative recovery across multiple follow-up visits, varying deformity types, and guide expectations.To objectively define and compare the complete 2-year postoperative recovery process among operative cervical only, thoracolumbar only, and combined deformity patients using area-under-the-curve (AUC) methodology.Retrospective review of 2 prospective, multicenter adult cervical and spinal deformity databases.One hundred seventy spinal deformity patients.Common health-related quality of life (HRQOL) assessments across both databases included the EuroQol 5-Dimension Questionnaire and Numeric Rating Scale (NRS) back pain assessment. In order to compare disability improvements, the Neck Disability Index (NDI) and the Oswestry Disability Index (ODI) were merged into one outcome variable, the ODI-NDI. Both assessments are gauged on the same scale, with minimal question deviation. Sagittal Radiographic Alignment was also assessed at pre- and all postoperative time points.Operative deformity patients18 years old with baseline (BL) to 2-year HRQOLs were included. Patients were stratified by cervical only (C), thoracolumbar only (T), and combined deformities (CT). HRQOL and radiographic outcomes were compared within and between deformity groups. AUC normalization generated normalized HRQOL scores at BL and all follow-up intervals (6 weeks, 3 months, 1 year, and 2 year). Normalized scores were plotted against follow-up time interval. AUC was calculated for each follow-up interval, and total area was divided by cumulative follow-up length, determining overall, time-adjusted HRQOL recovery (Integrated Health State, IHS). Multiple linear regression models determined significant predictors of HRQOL discrepancies among deformity groups.One hundred seventy patients were included (27 C, 27 T, and 116 CT). Age, BMI, sex, smoking status, osteoporosis, depression, and BL HRQOL scores were similar among groups (p. 05). T and CT patients had higher comorbidity severities (CCI: C 0.696, T 1.815, CT 1.699, p = .020). Posterior surgical approaches were most common (62.9%) followed by combined (28.8%) and anterior (6.5%). Standard HRQOL analysis found no significant differences among groups until 1-year follow-up, where C patients exhibited comparatively greater NRS back pain (4.88 vs. 3.65 vs. 3.28, p = .028). NRS Back pain differences between groups subsided by 2-years (p.05). Despite C patients exhibiting significantly faster ODI-NDI minimal clinically important difference (MCID) achievement (33.3% vs. 0% vs. 23.0%, p .001), all deformity groups exhibited similar ODI-NDI MCID achievement by 2-years (51.9% vs. 59.3% vs. 62.9%, p = 0.563). After HRQOL normalization, similar results were observed relative to the standard analysis (1-year NRS Back: C 1.17 vs. T 0.50 vs. CT 0.51, p .001; 2-year NRS Back: 1.20 vs. 0.51 vs. 0.69, p = .060). C patients exhibited a worse NRS back normalized IHS (C 1.18 vs. T 0.58 vs. CT 0.63, p = .004), indicating C patients were in a greater state of postoperative back pain for a longer amount of time. Linear regression models determined postoperative distal junctional kyphosis (adjusted beta: 0.207, p = .039) and osteoporosis (adjusted beta: 0.269, p = .007) as the strongest predictors of a poor NRS back IHS (model summary: RDespite C patients exhibiting a quicker rate of MCID disability (ODI-NDI) improvement, they exhibited a poorer overall recovery of back pain with worse NRS back scores compared with BL status and other deformity groups. Postoperative distal junctional kyphosis and osteoporosis were identified as primary drivers of a poor postoperative NRS back IHS. Utilization of the IHS, a single number adjusting for all postoperative HRQOL visits, in conjunction with predictive modelling may pose as an improved method of gauging the effect of surgical details and complications on a patient's entire recovery process.

BACKGROUND Proximal junctional kyphosis (PJK) is a common radiographic complication of adult spinal deformity (ASD) corrective surgery. Although previous literature has reported a 5 to 61% incidence of PJK, these studies are limited by small sample sizes and short-term follow-up. OBJECTIVE To assess the incidence of PJK utilizing a high-powered ASD database. METHODS Retrospective review of a prospective multicenter ASD database. Operative ASD patients > 18 yr old from 2009 to 2017 were included. PJK was defined as ≥ 10° for the sagittal Cobb angle between the inferior upper instrumented vertebra (UIV) endplate and the superior endplate of the UIV + 2. Chi-square analysis and post hoc testing assessed annual and overall incidence of acute (6-wk follow-up [f/u]), progressive (increase in degree of PJK from 6 wk to 1 yr), and delayed (1-yr, 2-yr, and 3-yr f/u) PJK development. RESULTS A total of 1005 patients were included (age: 59.3; 73.5% F; body mass index: 27.99). Overall PJK incidence was 69.4%. Overall incidence of acute PJK was 48.0%. Annual incidence of acute PJK has decreased from 53.7% in 2012 to 31.6% in 2017 (P = .038). Overall incidence of progressive PJK was 35.0%, with stable rates observed from 2009 to 2016 (P = .297). Overall incidence of 1-yr-delayed PJK was 9.3%. Annual incidence of 1-yr-delayed PJK has decreased from 9.2% in 2009 to 3.2% in 2016 (P

BACKGROUND Despite reports showing positive long-term functional outcomes following adult spinal deformity (ASD)-corrective surgery, it is unclear which factors affect the durability of these outcomes. OBJECTIVE To assess durability of functional gains following ASD-corrective surgery; determine predictors for postoperative loss of functionality. METHODS Surgical ASD patients > 18 yr with 3-yr Oswestry Disability Index (ODI) follow-up, and 1-yr postoperative (1Y) ODI scores reaching substantial clinical benefit (SCB) threshold (SCB

Objective We investigated the 30-day complication incidence and 1-year radiographic correction in obese patients undergoing surgical treatment of cervical deformity. Methods The patients were stratified according to World Health Organization's definition for obesity: obese, patients with a body mass index of ≥30 kg/m2; and nonobese, patients with a body mass index of Results A total of 124 patients were included, 53 obese and 71 nonobese patients. The 2 groups had a similar T1 slope minus cervical lordosis (obese, 37.2° vs. nonobese, 36.9°; P = 0.932) and a similar C2–C7 (−5.9° vs. −7.3°; P = 0.718) and C2–C7 (50.1 mm vs. 44.1 mm; P = 0.184) sagittal vertical axis. At the 1-year follow-up examination, the T1 pelvic angle (1.0° vs. −3.1°; P = 0.021) and C2–S1 sagittal vertical axis (−5.9 mm vs. −35.0 mm; P = 0.036) were different, and the T1 spinopelvic inclination (−1.0° vs. −2.9°; P = 0.123) was similar. The obese patients had a greater risk of overall short-term complications (odds ratio, 2.5; 95% confidence interval, 1.1–6.1) and infectious complications (odds ratio, 5.0; 95% confidence interval, 1.0–25.6). Conclusions Obese patients had a 5 times greater odds of developing infections after surgery for adult cervical deformity. Obese patients also showed significantly greater pelvic anteversion after cervical correction.

This study sought to assess comorbidity profiles unique to early-onset-scoliosis (EOS) patients by employing cluster analytics and to determine the influence of isolated comorbidity clusters on perioperative complications, morbidity and mortality using a high powered administrative database. The KID database was queried for ICD-9 codes pertaining to congenital and idiopathic scoliosis from 2003, 2006, 2009, 2012. Patients10 y/o (EOS group) were included. Demographics, incidence and comorbidity profiles were assessed. Comorbidity profiles were stratified by body systems (neurological, musculoskeletal, pulmonary, cardiovascular, renal). K-means cluster and descriptive analyses elucidated incidence and comorbidity relationships between frequently co-occurring comorbidities. Binary logistic regression models determined predictors of perioperative complication development, mortality, and extended length-of-stay (≥75th percentile). 25,747 patients were included (Age: 4.34, Female: 52.1%, CCI: 0.64). Incidence was 8.9 per 100,000 annual discharges. 55.2% presented with pulmonary comorbidities, 48.7% musculoskeletal, 43.8% neurological, 18.6% cardiovascular, and 11.9% renal; 38% had concurrent neurological and pulmonary. Top inter-bodysystem clusters: Pulmonary disease (17.2%) with epilepsy (17.8%), pulmonary failure (12.2%), restrictive lung disease (10.5%), or microcephaly and quadriplegia (2.1%). Musculoskeletal comorbidities (48.7%) with renal and cardiovascular comorbidities (8.2%, OR: 7.9 [6.6-9.4], p 0.001). Top intra-bodysystem clusters: Epilepsy (11.7%) with quadriplegia (25.8%) or microcephaly (20.5%). Regression analysis determined neurological and pulmonary clusters to have a higher odds of perioperative complication development (OR: 1.28 [1.19-1.37], p 0.001) and mortality (OR: 2.05 [1.65-2.54], p 0.001). Musculoskeletal with cardiovascular and renal anomalies had higher odds of mortality (OR: 1.72 [1.28-2.29], p 0.001) and extLOS (OR: 2.83 [2.48-3.22], p 0.001). EOS patients with musculoskeletal conditions were 7.9x more likely to have concurrent cardiovascular and renal anomalies. Clustered neurologic and pulmonary anomalies increased mortality risk by as much as 105%. These relationships may benefit pre-operative risk assessment for concurrent anomalies and adverse outcomes. Level of Evidence: III - Retrospective Prognostic Study.

BACKGROUND: Full-body stereographs for adult spinal deformity (ASD) have enhanced global deformity and lower-limb compensation associations. The advent of age-adjusted goals for classic ASD parameters (sagittal vertical axis, pelvic tilt, spino-pelvic mismatch [PI-LL]) has enabled individualized evaluation of successful versus failed realignment, though these remain to be radiographically assessed postoperatively. This study analyzes pre- and postoperative sagittal alignment to quantify patient-specific correction against age-adjusted goals, and presents differences in compensation in patients whose postoperative profile deviates from targets. METHODS: Single-center retrospective review of ASD patients ≥ 18 years with biplanar full-body stereographic x-rays. Inclusion: ≥ 4 levels fused, complete baseline and early (≤ 6-month) follow-up imaging. Correction groups generated at postoperative visit for actual alignment compared to age-adjusted ideal values for pelvic tilt, PI-LL, and sagittal vertical axis derived from clinically relevant formulas. Patients that matched exact ± 10-year threshold for age-adjusted targets were compared to unmatched cases (undercorrected or overcorrected). Comparison of spinal alignment and compensatory mechanisms (thoracic kyphosis, hip extension, knee flexion, ankle flexion, pelvic shift) across correction groups were performed with ANOVA and paired t tests. RESULTS: The sagittal vertical axis, pelvic tilt, and PI-LL of 122 patients improved at early postoperative visits (P .170); global sagittal angle decreased overall, reflecting global postoperative correction (8.3° versus 4.4°, P

The Clavien-Dindo grading allows for broad comparison of perioperative surgical complications, and a temporal analysis of complications following ASD-corrective surgery. NSQIP database was utilized from 2010 to 2014 to isolate patients. Complications were stratified by Clavien complication (Cc) grade, and patients grouped by highest Cc grade: I, II, III, IV, V. Secondary analysis grouped by minor (I, II, III) and severe (IV, V). Comorbidity burden was assessed with a NSQIP-modified Charlson Comorbidity Index (CCI) and frailty was measured with a 5-factor modified frailty index (mFI). From 2010 to 2014, 2971 patients (57 yrs, 58% F) underwent surgery for ASD (3.4 ± 4.1 levels; surgical approach: 46% anterior, 44% posterior, 10% combined), the rate of which increased 0.01% to 0.13. 32% suffered >1 complication. Patient breakdown by Cc grade: 0% I, 25% II, 3% III, 4% IV, 1% V. Severe Cc patients were more comorbid than minor Cc (CCI 2.8 vs 1.8), had longer operative times (394 min vs 251), and higher rates of osteotomy (29% vs 13%) and iliac fixation (16% vs 5%). Overall CCI (2.1–1.7) and perioperative complication rates (55–29%) decreased, despite increasing surgical invasiveness (2.8–4.5) and increasing frailty score (0.14 ± 0.15 vs 0.16 ± 0.16). Rates of Clavien grade II (39.80–22.20%) and IV (9.40–3.50%) complications also decreased, indicative of surgical improvements and effective preoperative patient selection. The decrease in CCI and increase in the modified frailty score may show that we are becoming more cognizant of discerning of comorbidities, but likely to not to have taken into account frailty, which may have an impact on future health socioeconomics.

Study Design: Retrospective review of a prospectively collected database. Objective: To predict the occurrence of hospital-acquired conditions (HACs) 30-days postoperatively and to compare predictors of HACs for spine surgery with other common elective surgeries. Methods: Patients ≥18 years undergoing elective spine surgery were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2013. Outcome measures included any HACs: superficial or deep surgical site infection (SSI), venous thromboembolism (VTE), urinary tract infection (UTI). Spine surgery patients were compared with those undergoing other common procedures. Random forest followed by multivariable regression analysis was used to determine risk factors for the occurrence of HACs. Results: A total of 90 551 elective spine surgery patients, of whom 3021 (3.3%) developed at least 1 HAC, 1.4% SSI, 1.3% UTI, and 0.8% VTE. The occurrence of HACs for spine patients was predicted with high accuracy (area under the curve [AUC] 77.7%) with the following variables: female sex, baseline functional status, hypertension, history of transient ischemic attack (TIA), quadriplegia, steroid use, preoperative bleeding disorders, American Society of Anesthesiologists (ASA) class, operating room duration, operative time, and level of residency supervision. Functional status and hypertension were HAC predictors for total knee arthroplasty (TKA), bariatric, and cardiothoracic patients. ASA class and operative time were predictors for most surgery cohorts. History of TIA, preoperative bleeding disorders, and steroid use were less predictive for most other common surgical cohorts. Conclusions: Occurrence of HACs after spine surgery can be predicted with demographic, clinical, and surgical factors. Predictors for HACs in surgical spine patients, also common across other surgical groups, include functional status, hypertension, and operative time. Understanding the baseline patient risks for HACs will allow surgeons to become more effective in their patient selection for surgery.

Retrospective review.Develop a simplified frailty index for cervical deformity (CD) patients.To improve preoperative risk stratification for surgical CD patients, a CD frailty index (CD-FI) incorporating 40 health deficits was developed. While novel, the CD-FI is clinically impractical due to the large number of factors needed for its calculation. To increase clinical utility, a simpler, modified CD-FI (mCD-FI) is necessary.CD patients (C2-C7 Cobb10°, CL10°, cSVA4 cm, or CBVA25°)18 year with preoperative CD-FI component factors. Pearson bivariate correlation assessed relationships between component deficits of the CD-FI and overall CD-FI score. Top deficits contributing to CD-FI score were included in multiple stepwise regression models. Deficits from model with largest R were dichotomized, and the mean score of all deficits calculated, resulting in mCD-FI score from 0 to 1. Patients were stratified by mCD-FI: Not Frail (NF,0.3), Frail (0.3-0.5), Severely Frail (SF,0.5). Means comparison tests established correlations between frailty category and clinical outcomes.Included: 121 CD patients (61 ± 11 yr, 60%F). Multiple stepwise regression models identified 15 deficits as responsible for 86% of the variation in CD-FI; these factors were used to construct the mCD-FI. Overall, mean mCD-FI was 0.31 ± 0.14. Breakdown of patients by mCD-FI category: NF: 47.9%, Frail: 46.3%, SF: 5.8%. Compared with NF and Frail, SF patients had the longest inpatient hospital stays (P = 0.042), as well as greater baseline neck pain (P = 0.033), inferior Neck Disability Index scores (P0.001) and inferior EQ-5D scores (P 0.001). Frail patients had higher odds of superficial infection (OR:1.1[1.0-1.2]), and SF patients had increased odds of mortality (OR:8.3[1.3-53.9]).Increased frailty, assessed by mCD-FI, correlated with increased length of stay, neck pain, and decreased health-related quality of life. Frail patients were at greater risk for infection, and severely frail patients had greater odds of mortality. This relationship between frailty and clinical outcomes suggests that mCD-FI offers clinical utility as a preoperative risk stratification tool.3.

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

Patient-specific rods designed based on a particular pre-operative plan are a recent advancement to help achieve desired operative alignment goals. This study investigated the role of pre-operative planning and patient-specific rods on post-operative alignment and outcomes. Patients were grouped according to use of pre-operative planning and patient-specific, pre-contoured rods (PLAN) or absence of planning/rods (NON). Pre-operative and post-operative alignment were measured: cervical sagittal vertical axis (cSVA), cervical lordosis (CL), T1 Slope minus CL (TS-CL). Alignment differences between the groups were assessed using independent and paired samples t-tests. 34 patients were identified (15 PLAN, 19 NON). Pre- and post-operative CL, cSVA and TS were similar between the two groups (p > 0.05), though pre-operative TS-CL was slightly higher in PLAN patients (28.13° versus 18.42°, p = 0.049). There were no improvement differences pre- to post-operative for CL, cSVA and TS between the groups (p > 0.05). However, PLAN patients exhibited a greater correction of TS-CL, with an average of 5.8° decrease versus a 3.5° increase in TS-CL for NON patients (p = 0.015). PLAN patients did not demonstrate a significant change from pre- to post-operative alignment for cSVA or TS-CL (cSVA: 27.5 mm to 31.1 mm, p = 0.255; TS-CL: 28.1° to 22.3°, p = 0.13), though their TS-CL did trend towards significant post-operative improvement. In contrast, NON patients worsened in cSVA and TS-CL post-operatively (cSVA: 21.8 mm to 30.3 mm, p

Distal junctional kyphosis (DJK) is a primary concern of surgeons correcting cervical deformity. Identifying patients and procedures at higher risk of developing this condition is paramount in improving patient selection and care.The present study aimed to develop a risk index for DJK development in the first year after surgery.This is a retrospective review of a prospective multicenter cervical deformity database.Patients over the age of 18 meeting one of the following deformities were included in the study: cervical kyphosis (C2-7 Cobb angle10°), cervical scoliosis (coronal Cobb angle10°), positive cervical sagittal imbalance (C2-C7 sagittal vertical axis (SVA)4 cm or T1-C610°), or horizontal gaze impairment (chin-brow vertical angle25°).Development of DJK at any time before 1 year.Distal junctional kyphosis was defined by both clinical diagnosis (by enrolling surgeon) and post hoc identification of development of an angle-10° from the end of fusion construct to the second distal vertebra, as well as a change in this angle by-10° from baseline. Conditional Inference Decision Trees were used to identify factors predictive of DJK incidence and the cut-off points at which they have an effect. A conditional Variable-Importance table was constructed based on a non-replacement sampling set of 2,000 Conditional Inference Trees. Twelve influencing factors were found; binary logistic regression for each variable at significant cutoffs indicated their effect size.Statistical analysis included 101 surgical patients (average age: 60.1 years, 58.3% female, body mass index: 30.2) undergoing long cervical deformity correction (mean levels fused: 7.1, osteotomy used: 49.5%, approach: 46.5% posterior, 17.8% anterior, 35.7% combined). In 2 years after surgery, 6% of patients were diagnosed with clinical DJK; however, 23.8% of patients met radiographic definition for DJK. Patients with neurologic symptoms were at risk of DJK (odds ratio [OR]: 3.71, confidence interval [CI]: 0.11-0.63). However, no significant relationship was found between osteoporosis, age, and ambulatory status with DJK incidence. Baseline radiographic malalignments were the most numerous and strong predictors for DJK: (1) C2-T1 tilt5.33 (OR: 6.94, CI: 2.99-16.14); (2) kyphosis-50.6° (OR: 5.89, CI: 0.07-0.43); (3) C2-C7 lordosis-12° (OR: 5.7, CI: 0.08-0.41); (4) T1 slope minus cervical lordosis36.4 (OR: 5.6, CI: 2.28-13.57); (5) C2-C7 SVA56.3° (OR: 5.4, CI: 2.20-13.23); and (6) C4_Tilt56.7 (OR: 5.0, CI: 1.90-13.1). Clinically, combined approaches (OR: 2.67, CI: 1.21-5.89) and usage of Smith-Petersen osteotomy (OR: 2.55, CI: 1.02-6.34) were the most important predictors of DJK.In a surgical cohort of patients with cervical deformity, we found a 23.8% incidence of DJK. Different procedures and patient malalignment predicted incidence of DJK up to 1 year. Preoperative T1 slope-cervical lordosis, cervical kyphosis, SVA, and cervical lordosis all strongly predicted DJK at specific cut-off points. Knowledge of these factors will potentially help direct future study and strategy aimed at minimizing this potentially dramatic occurrence.

Background: The study is a retrospective review of a multi-institutional database, aiming to determine predictors of non-depressed, satisfied adult spinal deformity (ASD) patients with good self-image at 2-year follow-up (2Y). ASD significantly impacts a patients’ psychological status. Following treatment, little is known about predictors of satisfied patients with high self-image and mental status. Methods: Inclusion: primary ASD pts >18 y/o with complete 2Y follow-up. Non-depressed [Short Form 36-mental component score (SF36-MCS) >42], satisfied patients (SRS22-satisfaction >3) with good self-image (SR22-self-image >3) at 2Y were isolated (happy). Happy and control patients were propensity-matched by baseline and 2Y leg pain, Charlson, frailty, and radiographic measures for the operative (OP) and non-operative cohorts (NOP). Health related quality of life (HRQL), surgical and radiographic metrics were compared. Regression models identified predictors of happy patients. Thresholds were calculated using area under the curve (AUC) and 95%CI. Results: Of 480 patients, 94 OP (happy: 47 vs. control: 47) and 92 NOP (46 each) reached inclusion. At baseline, groups had similar age, gender, Oswestry disability index (ODI) (OP: 39.13 vs. 37.49, NOP: 17.70 vs. 19.74) and SF36-physical component score (PCS) (OP: 33.51 vs. 35.04, NOP: 47.93 vs. 44.72). Despite similar (P>0.05) surgeries, length of stay (LOS), and radiographic outcomes between OP happy and control groups, happy had less peri-operative complications (31.9% vs. 57.4%, P=0.13), better 2Y ODI (17.77 vs. 29.98), SRS22 component, total, and SF36 scores (P 12) predicted happy OP patients, while baseline SRS-self-image (OR: 5.195, AUC: 0.740, cutoff: 3.5) and ODI improvement (OR: 1.087, AUC: 0.683, cutoff: >9) predicted happy NOP patients. Conclusions: Baseline mental-status, self-image and ODI improvement significantly impact long-term happiness in ASD patients. Despite equivalent management and alignment outcomes, operative and non-operative happy patients had better 2Y disability scores. Management strategies aimed at improving baseline mental-status, perception-of-deformity, and maximizing ODI may optimize treatment outcomes.

Study design This is a retrospective review of a single surgeon cervical deformity (CD) database. Objective Quantitatively describe the cervical extensor musculature in a CD population, and delineate associations between posterior musculature atrophy and progressive sagittal deformity. Summary of background data While fatty infiltration (FI; ie, posterior musculature atrophy) of lumbar extensor musculature has been associated with pain and deformity, little is known of the relationship between FI, CD, cervical sagittal alignment, and functionality. Methods CD patients [TS-CL>20 degrees, C2-C7 Cobb>10 degrees, CL>10 degrees, cervical sagittal vertical axis (cSVA)>4 cm, or chin-brow vertical angle>25 degrees] 18 years old and above, undergoing spinal fusion, with baseline T2-weighted magnetic resonance images were included. FI was assessed using dedicated imaging software at each intervertebral level from C2-C7. FI was gauged as a ratio of fat-free muscle cross-sectional area over total muscle cross-sectional area, with lower values indicating increasing FI. Influence of BL C2-C7 FI on patient-reported outcome measures (PROMs) and alignment was investigated. Multiple linear regression analysis (covariates: age, sex, body mass index, C2-C7 FI ratio) determined predictors of postoperative sagittal alignment and PROMs. Results Thirty-eight patients were included (age: 56.6, sex: 73.7% female, body mass index: 30.1, Charlson Comorbidity Index 0.61). BL deformity presentation: TS-CL 27.4 degrees, CL 2.1 degrees, cSVA: 27.2 mm. Mean baseline C2-C7 FI ratio was 0.65±0.11. Worsening FI was associated with malaligned baseline cSVA (rs=0.389, P=0.019), T1SS (rs=0.340, P=0.062), and impaired gait (rs=0.358, P=0.078). FI was not associated with BL PROMs (P>0.05). Following surgical intervention, regression models determined BL C2-C7 FI ratio as the strongest predictor of 1-year postoperative cSVA (β=-0.482, P=0.007, R=0.317). No associations between BL FI and postoperative PROMS or alignment parameters were observed (P>0.05). Conclusions Patients with significant CD demonstrate alterations in the posterior extensor musculature of the cervical spine. Atrophic changes with FI of these muscle groups is associated with worsening CD and is an important predictor of postoperative sagittal alignment. Level of evidence Level III.

Background: The recommended timing of surgical intervention for vertebral osteomyelitis (VO) is controversial; however, most studies are not sufficiently powered. Our goal was to investigate the associated effects of delaying surgery in VO patients on in-hospital complications, neurologic deficits, and mortality. Methods: Retrospective review of the National Inpatient Sample. Patients who underwent surgery for VO from 1998 to 2013 were identified using codes from the International Classification of Disease, Ninth Revision, Clinical Modification. Patients were stratified into groups based on incremental delay of surgery: 0-day delay (same-day surgery), 1-day delay, 2-day delay, 3- to 6-day delay, 7- to 14-day delay, and 14- to 30-day delay. Univariate analysis compared demographics and outcomes between groups. Multivariate logistic regression models calculated independent predictors of any complication, mortality, and neurologic deficits. A 0-day delay was the reference group. Results: A total of 34 465 patients were identified. Delayed groups were older (same day: 53.5 vs. 7–14-day delay: 61.1) and had a higher Deyo-Charlson score (same day: 0.4901 vs. 14–30-day delay: 1.66), length of stay (same day: 4.2 vs. 14–30-day delay: 34.04 days), and total charges (same day: $63,390.78 vs. 14-30-day delay: $245,752.4), all P Conclusion: VO patients who operate within 24 hours of admission are more likely to have desirable outcomes. Patients with delayed surgery had a significantly increased risk of developing any complication, mortality, and discharging with neurologic deficits. Level of Evidence: III. Clinical Relevance: Medically fit patients may benefit from earlier surgical management in order to reduce risk of postoperative complications, improve outcomes, and reduce overall hospital costs.

Chiari malformations are structural defects in the posterior fossa where the cerebellum displaces caudally into the foramen magnum and upper spinal canal. These malformations are classified by severity as Types 1-4, each presenting with different associated and/or concurrent conditions and anomalies. The aim of this study was to utilize a nationwide database to study patients with Chiari malformations including their concurrent diagnoses and associated anomalies. Using a retrospective review of the Nationwide Inpatient Sample (NIS) database from 2003 to 2012, Chiari malformations were assessed by Chiari type and rates of concurrence for various additional anomalies were evaluated using cross-tabulations. There were 305,726 national cases of Chiari Type 1, 119,632 cases of Chiari Type 2, 15,540 cases of Type 3, and 79,663 cases of Type 4. Overall 44.3% of Chiari patients have at least one concurrent anomaly. Stratified by Chiari Type, 7.1% of Type 1 patients, 12.3% of Type 2, and 100% of Type 3 and 4 have at least one concurrent anomaly. The most common isolated neurologic associations were tethered cord, syringomyelia, and hydrocephalus, while the most common anomaly clusters were syringomyelia and scoliosis in Type 1 (0.63), tethered cord syndrome and scoliosis (0.72%) in Type 2, encephalocele and acquired hydrocephalus (11.45%) in Type 3, and reduction deformity of the brain with acquired hydrocephalus (15.95%) in Type 4. Chiari malformations have strong associations with other abnormalities outside of known relationships in the current classification. While neurologic abnormalities are most common, additional body systems are frequently involved especially with worsening hindbrain defects.

Background: Cervical deformity (CD) surgery has become increasingly more common and complex, which has also led to reoperations for complications such as distal junctional kyphosis (DJK). Cost-utility analysis has yet to be used to analyze CD revision surgery in relation to the cost-utility of primary CD surgeries. The aim of this study was to determine the cost-utility of revision surgery for CD correction. Methods: Retrospective review of a multicenter prospective CD database. CD was defined as at least one of the following: C2–C7 Cobb >10°, cervical lordosis (CL) >10°, cervical sagittal vertical axis (cSVA) >4 cm, chin-brow vertical angle (CBVA) >25°. Quality-adjusted life year (QALY) were calculated by EuroQol Five-Dimensions questionnaire (EQ-5D) and Neck Disability Index (NDI) mapped to SF-6D index and utilized a 3% discount rate to account for residual decline to life expectancy (men: 76.9 years, women: 81.6 years). Medicare reimbursement at 30 days assigned costs for index procedures (9+ level posterior fusion, 4–8 level posterior fusion with anterior fusion, 2–3 level posterior fusion with anterior fusion, 4–8 level anterior fusion) and revision fusions (2–3 level, 4–8 level, or 9+ level posterior refusion). Cost per QALY gained was calculated. Results: Eighty-nine CD patients were included (61.6 years, 65.2% female). CD correction for these patients involved a mean 7.7±3.7 levels fused, with 34% combined approach surgeries, 49% posterior-only and 17% anterior-only, 19.1% three-column osteotomy. Costs for index surgeries ranged from $20,001–55,205, with the average cost for this cohort of $44,318 and cost per QALY of $27,267. Eleven revision surgeries (mean levels fused 10.3) occurred up to 1-year, with an average cost of $41,510. Indications for revisions were DJK (5/11), neurologic impairment [4], infection [1], prominent/painful instrumentation [1]. Average QALYs gained was 1.62 per revision patient. Cost was $28,138 per QALY for reoperations. Conclusions: CD revisions had a cost of $28,138 per QALY, in addition to the $27,267 per QALY for primary CD surgeries. For primary CD patients, CD surgery has the potential to be cost effective, with the caveats that a patient livelihood extends long enough to have the benefits and durability of the surgery is maintained. Efforts in research and surgical technique development should emphasize minimization of reoperation causes just as DJK that significantly affect cost utility of these surgeries to bring cost-utility to an acceptable range.

Study Design.Retrospective review of prospectively collected data.Objective.To assess the clinical impact and economic burden of the three most common hospital-acquired conditions (HACs) that occur within 30-day postoperatively for all spine surgeries and to compare these rates with other common sur

This retrospective cohort study describes adult cervical deformity(ACD) patients with Ames-ACD classification at baseline(BL) and 1-year post-operatively and assesses the relationship of improvement in Ames modifiers with clinical outcomes. Patients ≥ 18yrs with BL and post-op(1-year) radiographs were included. Patients were categorized with Ames classification by primary deformity descriptors (C = cervical; CT = cervicothoracic junction; T = thoracic; S = coronal) and alignment/myelopathy modifiers(C2-C7 Sagittal Vertical Axis[cSVA], T1 Slope-Cervical Lordosis[TS-CL], Horizontal Gaze[Horiz], mJOA). Univariate analysis evaluated demographics, clinical intervention, and Ames deformity descriptor. Patients were evaluated for radiographic improvement by Ames classification and reaching Minimal Clinically Important Differences(MCID) for mJOA, Neck Disability Index(NDI), and EuroQuol-5D(EQ5D). A total of 73 patients were categorized: C = 41(56.2%), CT = 18(24.7%), T = 9(12.3%), S = 5(6.8%). By Ames modifier 1-year improvement, 13(17.8%) improved in mJOA, 26(35.6%) in cSVA grade, 19(26.0%) in Horiz, and 15(20.5%) in TS-CL. The overall proportion of patients without severe Ames modifier grades at 1-year was as follows: 100% cSVA, 27.4% TS-CL, 67.1% Horiz, 69.9% mJOA. 1-year post-operatively, severe myelopathy(mJOA = 3) prevalence differed between Ames-ACD descriptors (C = 26.3%, CT = 15.4%, T = 0.0%, S = 0.0%, p = 0.033). Improvement in mJOA modifier correlated with reaching 1-year NDI MCID in the overall cohort (r = 0.354,p = 0.002). For C descriptors, cSVA improvement correlated with reaching 1-year NDI MCID (r = 0.387,p = 0.016). Improvement in more than one radiographic Ames modifier correlated with reaching 1-year mJOA MCID (r = 0.344,p = 0.003) and with reaching more than one MCID for mJOA, NDI, and EQ-5D (r = 0.272,p = 0.020). In conclusion, improvements in radiographic Ames modifier grades correlated with improvement in 1-year postoperative clinical outcomes. Although limited in scope, this analysis suggests the Ames-ACD classification may describe cervical deformity patients’ alignment and outcomes at 1-year.

Study Design:Retrospective review of prospective database.Objective:Complication rates for adult spinal deformity (ASD) surgery vary widely because there is no accepted system for categorization. Our objective was to identify the impact of complication occurrence, minor-major complication, and Clavien-Dindo complication classification (Cc) on clinical variables and patient-reported outcomes.Methods:Complications in surgical ASD patients with complete baseline and 2-year data were considered intraoperatively, perioperatively (6 weeks). Primary outcome measures were complication timing and severity according to 3 scales: complication presence (yes/no), minor-major, and Cc score. Secondary outcomes were surgical outcomes (estimated blood loss [EBL], length of stay [LOS], reoperation) and health-related quality of life (HRQL) scores. Univariate analyses determined complication presence, type, and Cc grade impact on operative variables and on HRQL scores.Results:Of 167 patients, 30.5% (n = 51) had intraoperative, 48.5% (n = 81) had perioperative, and 58.7% (n = 98) had postoperative complications. Major intraoperative complications were associated with increased EBL ( P < .001) and LOS ( P = .0092). Postoperative complication presence and major postoperative complication were associated with reoperation ( P < .001). At 2 years, major perioperative complications were associated with worse ODI, SF-36, and SRS activity and appearance scores ( P < .02). Increasing perioperative Cc score and postoperative complication presence were the best predictors of worse HRQL outcomes ( P < .05).Conclusion:The Cc Scale was most useful in predicting changes in patient outcomes; at 2 years, patients with raised perioperative Cc scores and postoperative complications saw reduced HRQL improvement. Intraoperative and perioperative complications were associated with worse short-term surgical and inpatient outcomes.

Retrospective analysis of New York State Inpatient Database years 2004-2013.Assess rates of spinal diagnoses and procedures before and after bariatric surgery (BS).BS for morbid obesity helps address common comorbidity burdens and improves quality of life for patients. The effects of BS on spinal disorders and surgical intervention have yet to be investigated.Patients included in analysis if they underwent BS and were seen at the hospital before and after this intervention. Spinal conditions and rates of surgery assessed before and after BS using χ 2 tests for categorical variables. Multivariable logistic regression analysis used to compare rates in BS patients to control group of nonoperative morbidly obese patients. Logistic testing controlled for comorbidities, age, biological sex.A total of 73,046 BS patients included (age 67.88±17.66 y, 56.1% female). For regression analysis, 299,504 nonbariatric, morbidly obese patients included (age 53.45±16.52 y, 65.6% female). Overall, rates of spinal symptoms decreased following BS (7.40%-5.14%, P0.001). Cervical, thoracic, lumbar spine diagnoses rates dropped from 3.28% to 2.99%, 2.91% to 2.57%, and 5.39% to 3.92% (all P0.001), respectively. Most marked reductions seen in cervical spontaneous compression fractures, cervical disc herniation, thoracic radicular pain, spontaneous lumbar compression fractures, lumbar spinal stenosis, lumbar spondylosis. Controlling for comorbidities, age and sex, obese nonbariatric patients more likely to have encounters associated with several cervical, thoracic or lumbar spinal diagnoses and procedures, especially for cervical spontaneous compression fracture, radicular pain, lumbar spondylosis, lumbar spinal stenosis, posterior procedures. BS significantly lowered comorbidity burden for many specific factors.BS lowered rates of documented spinal disorders and procedures in a morbidly obese population. These findings provide evidence of additional health benefits following BS, including reduction in health care encounters for spinal disorders and rates of surgical intervention.

Ossification of the posterior longitudinal ligament (OPLL) is characterized by ectopic bone formation within the ligament and can elicit cervical spinal canal stenosis. Surgical treatment for OPLL is debated in the literature. This study examined nationwide data to estimate the prevalence of cervical OPLL (C-OPLL) and investigated trends in surgical treatment and outcomes.A retrospective cross-sectional study was conducted of the National Inpatient Sample (NIS) database for patients with a diagnosis code for C-OPLL (ICD-9-CM 723.7) from 2005 to 2013. NIS supplied hospital- and yearadjusted weights allowed for accurate assessment of prevalence. Descriptive statistics assessed patient demographics, comorbidities, surgical factors, and complications. Trends were analyzed using chi-squared, ANOVA, and independent sample t-tests.A total of 4,601 C-OPLL discharges were identified (56.7 years, 43% female). The prevalence of C-OPLL has increased from 0.7/100,000 in 2005 to 2.1/100,000 in 2013. Among hospitalized C-OPLL patients, 89.1% underwent surgery, with 62.1% undergoing an anterior-only (A) approach, 21.5% posterior-only (P), and 16.4% combined (AP). Rates of anterior- and decompression-only surgeries have declined since 2005, from 67.5% to 44.4% and 21.6% to 14.8%, respectively (p0.001 for both). Corpectomy rates have dramatically increased, from 3.6% to 27.2% (p0.001). Overall complication rates have increased 2.5% since 2005 (p0.001) with higher rates of dysphagia (0.7%) and dural tears (5.6%) associated with A-only surgeries (p0.001 for both). The overall mortality rate was 0.8%, with P surgery associated with the highest rate, 1.6% (p = 0.002).The rate of hospitalization for C-OPLL has increased over the last decade as have morbidity rates for C-OPLL discharges. Anterior-only surgeries were associated with higher complication rates. Surgical rates have remained constantsince 2005, butrates of anterior-only and decompression-only procedures have decreased in favor of posterior-only and combined-approach surgeries.

Study Design: Retrospective review of single institution. Objective: To assess the relationship between Patient-Reported Outcomes Measurement Information System (PROMIS) and Oswestry Disability Index (ODI) scores in thoracolumbar patients. Methods: Included: Patients ≥18 years with a thoracolumbar spine condition (spinal stenosis, disc herniation, low back pain, disc degeneration, spondylolysis). Bivariate correlations assessed the linear relationships between ODI and PROMIS (Physical Function, Pain Intensity, and Pain Interference). Correlation cutoffs assessed patients with high and low correlation between ODI and PROMIS. Linear regression predicted the relationship of ODI to PROMIS. Results: A total of 206 patients (age 53.7 ± 16.6 years, 49.5% female) were included. ODI correlated with PROMIS Physical Function ( r = −0.763, P < .001), Pain Interference ( r = 0.800, P < .001), and Pain Intensity ( r = 0.706, P < .001). ODI strongly predicted PROMIS for Physical Function ( R2 = 0.58, P < .001), Pain Intensity ( R2 = 0.50, P < .001), and Pain Interference ( R2 = 0.64, P < .001); however, there is variability in PROMIS that ODI cannot account for. ODI questions about sitting and sleeping were weakly correlated across the 3 PROMIS domains. Linear regression showed overall ODI score as accounting for 58.3% ( R2 = 0.583) of the variance in PROMIS Physical Function, 63.9% ( R2 = 0.639) of the variance in Pain Interference score, and 49.9% ( R2 = 0.499) of the variance in Pain Intensity score. Conclusions: There is a large amount of variability with PROMIS that cannot be accounted for with ODI. ODI questions regarding walking, social life, and lifting ability correlate strongly with PROMIS while sitting, standing, and sleeping do not. These results reinforce the utility of PROMIS as a valid assessment for low back disability, while indicating the need for further evaluation of the factors responsible for variation between PROMIS and ODI.

Aims The objectives of this study were to (1) characterize the epidemiology of liver metastases at the time of primary cancer diagnosis (synchronous liver metastases), (2) characterize the incidence trends of synchronous liver metastases from 2010−2015 and (3) assess survival of patients with synchronous liver metastases. Methods The Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2015 was queried to obtain cases of patients with liver metastases at the time of primary cancer diagnosis. The primary cancers with an incidence rate of liver metastasis >0.1 are presented in this analysis. Results Among 2.4 million cancer patients, 5.14 % of cancer patients presented with synchronous liver metastases. The most common primary site was breast cancers for younger women (ages 20–50), and colorectal cancers for younger men. As patients get older, a more heterogenous population of the top cancers with liver metastases emerges including esophageal, stomach, small intestine, melanoma, and bladder cancer in addition to the large proportion of lung, pancreatic, and colorectal cancers. The 1-year survival of all patients with liver metastases was 15.1 %, compared to 24.0 % in those with non-hepatic metastases. Regression analysis showed that the presence of liver metastasis was associated with reduced survival, particularly in patients with cancers of the testis, prostate, breast, and anus, and in those with melanoma. Conclusions The most common primary sites for patients with liver metastases varied based on age at diagnosis. Survival for patients with liver metastasis was significantly decreased as compared to patients without liver metastasis.

Background: This study evaluated the incidence of de novo bone metastasis across all primary cancer sites and their impact on survival by primary cancer site, age, race, and sex. Questions/purposes: Our objectives were (I) characterize the epidemiology of de novo bone metastasis with respect to patient demographics, (II) characterize the incidence by primary site, age, and sex (2010–2015), and (III) compare survival of de novo metastatic cancer patients with and without bone metastasis. Methods: This is a retrospective, population-based study using nationally representative data from the Surveillance, Epidemiology, and End Results program, 2010–2015. Incidence rates by year of diagnosis, annual percentage changes, Kaplan-Meier, univariate and multiple Cox regression models are included in the analysis. Results: Of patients with cancer in the SEER database, 5.1% were diagnosed with metastasis to bone, equaling ~18.8 per 100,000 bone metastasis diagnoses in the US per year (2010–2015). For adults >25, lung cancer is the most common primary site (2015 rate: 8.7 per 100,000) with de novo bone metastases, then prostate and breast primaries (2015 rates: 3.19 and 2.38 per 100,000, respectively). For patients

Background The objectives of this study were to characterize (1) epidemiology of brain metastases at the time of primary cancer diagnosis, (2) incidence and trends of synchronous brain metastases from 2010 to 2015, and (3) overall survival (OS) of patients with synchronous brain metastases. Methods A total of 42 047 patients with synchronous brain metastases from 2010 to 2015 were identified from the Surveillance, Epidemiology, and End Results database. Descriptive analysis was utilized to analyze demographics and incidence. The Kaplan–Meier method and a Cox proportional hazards model were utilized to evaluate potential prognostic factors for OS. Results The majority of patients were diagnosed from age older than 50 (91.9%). Common primary sites included lung (80%), melanoma (3.8%), breast (3.7%), and kidney/renal pelvis (3.0%). Among pediatric patients, common primaries included kidney/renal pelvis and melanomas. The incidence was roughly 7.3 persons/100 000. Synchronous brain metastases were associated with significantly poorer OS compared to extracranial metastases alone (hazard ratio [HR] =1.56; 95% CI: 1.54–1.58; P < .001). Among patients with brain metastases, male gender (HR = 1.60 vs 1.52), age older than 65 years (HR = 1.60 vs 1.46), synchronous liver, bone, or lung metastases (HR = 1.61 vs 1.49), and earlier year of diagnosis (HR = 0.98 for each year following 2010) were associated with significantly poorer OS. Conclusions The vast majority of brain metastases are from lung primaries. Synchronous brain metastases are associated with poorer OS compared to extracranial metastases alone.

Background: The rate of mortality in surgical procedures involving the lumbar spine has historically been low, and as a result, there has been difficulty providing accurate quantitative mortality rates to patients in the preoperative planning phase. Awareness of these mortality rates is essential in reducing postoperative complications and improving outcomes. Additionally, mortality rates can be influenced by procedure type and patient profile, including demographics and comorbidities. The purpose of this study is to assess rates and risk factors associated with mortality in surgical procedures involving the lumbar spine using a large national database. Methods: The Nationwide Inpatient Sample database was reviewed from 2003 to 2012. A total of 803,949 patients age 18 years or older were identified by ICD-9CM procedure codes for spinal fusion or decompression of the lumbar spine. Mortality was stratified based on type of procedure (simple or complex fusion, decompression), patient demographics and comorbidities, and in-hospital complications. Binary logistic regression was used to identify the risk of death while controlling for comorbidities, race, sex, and procedure performed. Significance was defined as P Results: Mortality for all patients requiring surgery of the lumbar spine was 0.13%. Mortality based on procedure type was 0.105% for simple fusions, 0.321% for complex fusions, and 0.081% for decompression only. Increased mortality was observed demographically in patients who were male (odds ratio [OR]: 1.75; 95% confidence interval [CI]: 1.51–2.03), black (OR: 1.40; CI: 1.10–1.79), ages 65–74 (OR: 1.46; CI: 1.25–1.70), and age 75+ (OR: 2.70; CI: 2.30–3.17). Comorbidities associated with the greatest increase in mortality were mild (OR: 10.04; CI: 7.76–13.01) and severe (OR: 26.47; CI: 16.03–43.70) liver disease and congestive heart failure (OR: 4.57; CI: 3.77–5.53). The complications with the highest mortality rates were shock (OR: 20.67; CI: 13.89–30.56) and pulmonary embolism (OR: 20.15; CI: 14.01–29.00). Conclusions: From 2003 to 2012, the overall mortality rate in 803,949 lumbar spine surgery patients was 0.13%. Risk factors that were significantly associated with increased mortality rates were male gender, black race, and ages 65–74 and 75+. Comorbidities associated with an increased mortality rate were mild and severe liver disease and congestive heart failure. Inpatient complications with the highest mortality rates were shock and pulmonary embolism. These findings can be helpful to surgeons providing preoperative counseling for patients considering elective lumbar procedures and for allocating resources to treat and prevent perioperative complications leading to mortality. Level of Evidence: 3.

CD development secondary to PJK was recently documented in adult spinal deformity patients after surgical correction for thoracolumbar ASD. This study analyzes surgical management of patients with CD secondary to proximal junctional kyphosis (PJK) versus patients with primary CD. Retrospective review of multicenter cervical deformity (CD) database. CD defined as at least one of the following: C2-C7 coronal Cobb 10°, cervical lordosis (CL) 10°, cervical sagittal vertical axis (cSVA) 4cm, CBVA 25°. Patients were grouped into those with PJK (UIV +2 -10°) prior to cervical surgery versus who don't (Non-PJK). Independent t-tests and chi-squared tests compared radiographic, clinical, and surgical metrics between PJK and non-PJK groups. Of 123 eligible CD patients, 26(21.1%) had radiographic PJK prior to cervical surgery. PJK patients had significantly greater T2-T12 thoracic kyphosis (-58.8° vs -45.0°, p = 0.002), cSVA (49.1 mm vs 38.9 mm, p = 0.020), T1 Slope (42.6° vs 28.4°, p 0.001), TS-CL (44.1° vs 35.6°, p = 0.048), C2-T3 SVA (98.8 mm vs 75.8 mm, p = 0.015), C2 Slope (45.4° vs 36.0°, p = 0.043), and CTPA (6.4° vs 4.6°, p = 0.005). Comparing their surgeries, the PJK group had significantly more levels fused (10.7 vs 7.4, p = 0.01). There was significantly greater blood loss in PJK patients (1158 ± 1063vs 738 ± 793 cc, p = 0.028); operative time, surgical approach, and BMP-2 use were similar (all p 0.05). PJK patients experienced higher rates of complications 30 and 90 days post-operatively (23.1% vs. 5.2%, p = 0.004; 30.8% vs. 19.6%, p = 0.026), and more instrumentation failure 30 days postoperatively (7.8% vs. 1.0%, p = 0.004). Patients with cervical deformity secondary to PJK had worse baseline CD, despite no differences in HRQL or demographics. Surgical correction of CD associated with PJK required more invasive surgery and had higher complication rates than non-PJK patients, despite achieving similar clinical outcomes.

Background Context With advances in the understanding of adult spinal deformity (ASD), more complex osteotomy and fusion techniques are being implemented with increasing frequency. Patients undergoing ASD corrections infrequently require extended acute care, longer inpatient stays, and are discharged to supervised care. Given the necessity of value-based health care, identification of clinical indicators of adverse discharge disposition in ASD surgeries is paramount. Purpose Using the nationwide and surgeon-created databases, the present study aimed to identify predictors of adverse discharge disposition after ASD surgeries and view the corresponding differences in charges. Study Design/Setting This is a retrospective analysis of patients on the National Surgical Quality Improvement Program (NSQIP) database and of cost data from Medicare PearlDiver Database. Patient Sample Patients undergoing thoracolumbar surgery for correction of ASD were included in the study. Outcome Measures Primary analysis was performed to compare patients discharged to home with patients who either expired or were discharged to locations other than home. Secondary analysis was performed to determine the cost differences across discharge groups. Methods Patients on NSQIP undergoing thoracolumbar ASD-corrective surgery with a primary diagnosis of scoliosis (ICD-9 code 737.x) and over the age of 18 were isolated. Predictors (demographic, clinical, and complications) of not-home (NH; rehab or skilled nursing facility) discharge were analyzed using binary logistic regression controlling for levels fused, decompressions, osteotomies, and revisions. Average 30- and 90-day costs of care were reported in home, rehab, and skilled nursing facility discharge groups in patients undergoing 8+ level thoracolumbar fusion. Results A total of 1,978 patients undergoing lumbar ASD-corrective surgery were included for analysis (average age: 59.3 years, sex: 64% female). Average length of stay was 6.58 days. On multivariate regression analysis, age over 60 years (odds ratio [OR]: 0.28, confidence interval [CI]: 0.22–0.34) and female sex (p=.003) were independent predictors of adverse discharge status. Partially dependent preoperational functional status, defined as reliance on another person to complete some activities of daily living, increased likelihood of adverse discharge disposition (OR: 0.57, CI: 0.35–0.90). Despite controlling for all clinical variables except for the ones specific to each analysis, Smith-Petersen osteotomy (OR: 0.51, CI: 0.40–0.64), interbody device placement (OR: 0.80, CI: 0.64–0.98), and fixation to the iliac (OR: 0.54, CI: 0.41–0.70) increased the likelihood of adverse discharge. Complications most associated with adverse discharge were urinary tract infections (OR: 0.34, CI: 0.21–0.57) and blood transfusions (OR: 0.42, CI: 0.34–0.52). Relative to home discharge, 30-day costs of care were +$21,061 more expensive in rehab discharges, but not different in skilled nursing facility discharges (+$5,791, p=.177). The 90-day costs of care were $23,815 in rehab discharges (p Conclusions Discharge destination to rehabilitation has a significant impact on the cost of thoracolumbar ASD surgeries. Patient selection can predict patients at higher risk of discharges to rehab or skilled nursing facility.

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.