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Local control remains a vexing problem in the management of chordoma despite advances in operative techniques and radiotherapy (RT) protocols. Existing studies show satisfactory local control rates with different treatment modalities. However, those studies with minimum follow-up more than 4 years demonstrate increasing rates of local failure. Therefore, mid-term local survival rates may be inadvertently elevated by studies with less than 4 years follow-up. The purpose of this study is to report the mid-term results of primary spinal chordoma treated with en bloc resection and proton-based RT with minimum 5 years of follow-up. Retrospective, single-center, cohort study. Patients undergoing primary surgical excision of a spine or sacral chordoma tumor between 1990 and 2016 at a single-institution were included. Patients were included if they had a local failure at any time, or they had a minimum of 5 years of follow up with no local failure. Patients were excluded if a prior surgical excision was performed or metastases were present at the time of referral. The outcome measures were local recurrence-free interval (LRFI) and overall survival (OS). Demographic, clinical, oncologic and surgical variables, including margin status, as well as radiation doses and schedule (neoadjuvant, adjuvant, or both) were compared using Wilcoxon rank-sum or chi-squared testing. The goal RT dose was 70 Gray (total) and patients were stratified based on completing (C70) or receiving incomplete (I70) dosing. Overall survival (OS) and local-recurrence free interval (LRFI) were calculated using the Kaplan-Meier method. No funding was obtained for this work. Seventy-six patients were included in the final analysis. All patients had a minimum of 5-year follow-up (median 9.3 years, range 5.1–24.7 years). There were no significant clinical differences between the C70 and I70 RT groups. OS was greater for the C70 RT group (5-year OS 82% vs. 63%, p=.001). There was similar OS for the positive margin group (5-year OS 70% vs. 61%, p=.266). LRFI was greater for the C70 RT group (5-year OS 93% vs. 78%, p=.017). There was similar LRFI for the positive margin group (5-year OS 90% versus 87%, p=.810). Chordoma outcomes trend towards diminishing LRFI rates in the literature. Here we report the results of the operative management of primary spinal chordoma with minimum five year follow-up, the addition of C70 RT to surgical excision conferred a benefit to OS and local recurrence. [ABSTRACT FROM AUTHOR]

This research letter discusses the importance of minimum follow-up in studying the recurrence of chordoma, a rare type of tumor. The study analyzed the timing of local recurrence (LR) and distant metastasis after surgical resection of chordoma. The results showed that the mean time to LR was 5.6 years, while the mean time to distant metastasis was 4.1 years. The study emphasizes the need for a minimum 5-year follow-up in clinical efficacy research for chordoma. [Extracted from the article]

Background Context: Proximal junctional failure (PFJ) is a common and dreaded complication of adult spinal deformity. Previous research has identified parameters associated with the development of PJF and the search for radiographic and clinical variables continues in an effort to decrease the incidence of PFJ. The lordosis distribution index (LDI) is a parameter not based on pelvic incidence. Ideal values for LDI have been established in prior literature with demonstrated association with PJF.Purpose: The purpose of this study is compare PJF and mechanical failure rates between patients with ideal and nonideal LDI cohort.Study Design: This is a retrospective, single-center case-controlled study.Patient Sample: Adult patients who underwent surgical treatment for spinal deformity as defined by the SRS-Schwab criteria between 2001 and 2016 were included. Furthermore, fusion constructs spanned at least four vertebral segments with the upper instrumented vertebra (UIV) T9 or caudal. Patients who were under the age of 18, those with radiographic data less than 1 year, and those with neoplastic or trauma etiologies were excluded. Prior thoracolumbar spine surgery was not an exclusion criterion.Outcome Measures: The outcome measures were physiologic in nature: The primary outcome was defined as PFJ. The International Spine Study Group (ISSG) definition for PJF was used, which includes postoperative fracture of the UIV or UIV+1, instrumentation failure at UIV, PJA increase greater than 15° from preoperative baseline or extension of the construct needed within 6 months. Secondary outcomes included extension of the construct after 6 months or revision due to instrumentation failure, pseudarthrosis or distal junctional failure.Methods: A portion of this project was funded through National Institute of Health Grant 5UL1TR001067-05. The authors have no conflict of interest related to this study. The records of patients meeting the inclusion criteria were reviewed. Clinical and radiographic data were extracted and analyzed. Univariate cox proportional hazard models were used to identify factors associated with mechanical failure and included in a multivariate Cox proportional hazards model.Results: There were 187 patients that met the inclusion criteria. Univariate analysis demonstrated the number of levels fused, instrumentation to the sacrum or pelvis, PI-LL difference between pre- and postoperative states, T1-SPI, T9-SPI, and postoperative LDI (treated as a continuous variable). When LDI was treated as a categorical variable using an LDI cutoff of less than 0.5 for hypolordotic, 0.5 to 0.8 for aligned and greater than 0.8 for hyperlordotic, there was no difference in failure rates between the two groups.Conclusions: Lumbar lordosis is an important parameter in adult deformity. However, the LDI is an imperfect variable and previously developed categories did not show differences in failure rates in this cohort. [ABSTRACT FROM AUTHOR]

Background: Advanced-imaging screening for asymptomatic blunt cerebrovascular injury is controversial. Vertebral artery injury (VAI) is most commonly associated with cervical spine fracture, and many guidelines advocate indiscriminate screening for all cervical spine fractures. The purpose of this study was to determine whether the addition of computed tomographic angiography (CTA) results in a change in management for patients with cervical spine fractures.Methods: Adult patients treated for acute cervical spine fractures after blunt trauma during the period of 2000 to 2015 were retrospectively identified. Patients who sustained a penetrating trauma or who had a history of neoplasm or prior cervical spine surgery were excluded. The following variables were recorded: age, biologic sex, race, medical comorbidities, Injury Severity Score (ISS), mechanism of injury, whether CTA of the neck was obtained in addition to computed tomography (CT), cervical spine fracture characteristics and treatment, and the presence of VAI. Recommendation for a change in management with antithrombotic therapy was the primary outcome measure. Detection of stroke and of VAI were secondary outcomes. Propensity-score matching was performed to negate the significant differences in baseline demographic and clinical characteristics.Results: A total of 3,943 patients were screened for eligibility, and 2,831 patients met the inclusion criteria. Propensity-score matching yielded 1 cohort who underwent CT + CTA and 1 cohort who underwent CT alone, both with 644 patients and equivalent demographic and clinical characteristics. CTA identified definite or indeterminate VAI in 113 patients, and for 62 patients, antithrombotic therapy was recommended. In the CT-alone cohort, VAI was identified in 11 patients incidentally through other imaging, and antithrombotic therapy was recommended for 8 patients. Two patients in the CT + CTA group had major adverse bleeding events as a result of the initiation of antithrombotic therapy. There were no preventable strokes in either group.Conclusions: The addition of CTA increased detection of VAI and the recommendation for antithrombotic therapy. There were no preventable strokes in either cohort and 2 major adverse bleeding events attributable to the recommended pharmacologic antithrombotic therapy. Nonselective screening is not warranted and should be limited to a high-risk subset of patients.Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Study Design: Adult patients who received computed tomography (CT) alone or CT-magnetic resonance imaging (MRI) for the evaluation of cervical spine injury.Objective: To evaluate the utility of CT-MRI in the diagnosis of cervical spine injury using propensity-matched techniques.Summary Of Background Data: The optimal evaluation (CT alone vs. CT and MRI) for patients with suspected cervical spine injury in the setting of blunt trauma remains controversial.Methods: The primary outcome was the identification of a cervical spine injury, with decision for surgery and change in management considered secondarily. A propensity score was developed based on the likelihood of receiving evaluation with CT-MRI, and this score was used to balance the cohorts and develop two groups of patients around whom there was a degree of clinical equipoise in terms of the imaging protocol. Logistic regression was used to evaluate for significant differences in injury detection in patients evaluated with CT alone as compared to those receiving CT-MRI.Results: Between 2007 and 2014, 8060 patients were evaluated using CT and 693 with CT-MRI. Following propensity-score matching, each cohort contained 668 patients. There were no significant differences between the two groups in baseline characteristics. The odds of identifying a cervical spine injury were significantly higher in the CT-MRI group, even after adjusting for prior injury recognition on CT (odds ratios 2.6; 95% confidence interval 1.7-4.0; P < 0.001). However, only 53/668 patients (8%) in the CT-MRI group had injuries identified on MRI not previously recognized by CT. Only a minority of these patients (n = 5/668, 1%) necessitated surgical intervention.Conclusion: In this propensity-matched cohort, the addition of MRI to CT alone identified missed injuries at a rate of 8%. Only a minority of these were serious enough to warrant surgery. This speaks against the standard addition of MRI to CT-alone protocols in cervical spine evaluation after trauma.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

The article presents the discussion on investigating the treatment of lumbar stenosis. Topics include showing the change in pain and function after surgery against perioperative complications as best exemplified by the Spine Patient Outcomes Research Trial (SPORT); and examining all-cause mortality and total costs after surgery compared with nonsurgical treatments.

Study Design: Clinical case series.Objective: To investigate the efficacy of intraoperative neuromonitoring in pediatric cervical spine surgery.Summary Of Background Data: Intraoperative neuromonitoring (IONM) consisting of somatosensory-evoked potentials (SSEP) and transcranial motor-evoked potentials (tcMEP) has been shown to effectively prevent permaneny neurologic injury in deformity surgery. The role of IONM during pediatric cervical spine surgery is not well documented. Advances in cervical spine instrumentation have expanded the surgical options in pediatric populations. The goal of this study is to report the ability of IONM to detect neurologic injury during pediatric cervical spine instrumentation.Methods: A single institution database was queried for pediatric-aged patients who underwent cervical spine instrumentation and fusion between 2011 and 2014. Age, diagnosis, surgical indication, number of instrumented levels, and a complete IONM were extracted. Sensitivity and specificity for the detection of neurologic deficits were calculated with exact 95% confidence intervals. Positive and negative predictive values were calculated with estimated 95% confidence intervals.Results: Sixty-seven patients who underwent cervical spine instrumentation were identified with a mean age of 11.6 years (range 1-18). Diagnoses included instability (27), congenital (11), kyphosis (8), fracture (7), tumor (7), arthritis (4), and basilar invagination (3). Mean number of vertebral levels fused was 4 (range 2-7). All patients underwent cervical instrumentation with SSEP and tcMEP monitoring. A significant change in tcMEP monitoring was observed in 7 subjects (10%). There were no corresponding SSEP changes in these patients. The sensitivity of combined IONM was 75% [95% CI = 24.9, 98.7] and the specificity was 98.5% [92.7, 99.9].Conclusion: tcMEP is a more sensitive indicator to spinal cord injury than SSEP, which is consistent with previous studies. IONM changes in 10% of a patient population are significant enough to warrant intraoperative determination if true SCI has occurred or is underway and intervene accordingly.Level Of Evidence: 4. [ABSTRACT FROM AUTHOR]

The article by Karamian I et al i provides us with insight on the fate of patients who develop surgical site infection (SSI) after thoracolumbar spinal fusion. Eur Spine J. 2018; 27:, 2518- 28. 3 Urquhart JC, Gurr KR, Siddiqi F. The impact of surgical site infection on patient outcomes after open posterior instrumented thoracolumbar surgery for degenerative disorders. [Extracted from the article]

Background: Limited health literacy exacerbates health inequity and has serious implications for patient care. It hinders successful communication and comprehension of relevant health information, which can lead to suboptimal care. Despite the evidence regarding the significance of health literacy, the topic has received little consideration in orthopedic spine patients.Purpose: To investigate the prevalence of- and factors associated with limited health literacy among outpatients presenting to a tertiary urban academic hospital-based orthopedic spine center.Study Design: Cross-sectionals.Patient Sample: Patients 18 years of age or older seen at a tertiary urban academic hospital-based multi-surgeon outpatient spine center.Outcome Measures: The Newest Vital Sign (NVS) health literacy assessment.Methods: Between December 2021 and March 2022, 447 consecutive English-speaking patients over the age of 18 years and new to the outpatient spine clinic were approached for participation in a cross-sectional survey study, of which 405 agreed to participate. Patients completed the Newest Vital Sign (NVS) health literacy assessment tool, the Rapid Estimation of Adult Literacy in Medicine Short Form (REALM-SF), and a sociodemographic survey (including race/ethnicity, level of education, employment status, income, and marital status). The NVS scores were divided into limited (0-3) and adequate (4-6) health literacy. REALM-SF scores were classified into reading levels below ninth grade (0-6) or at least ninth grade (7). Additional demographic data was extracted from patient records. Online mapping tools were used to collect the Social Vulnerability Index (SVI) and the Area Deprivation Index (ADI) for each patient. Subsequently, multivariable regression modeling was performed to identify independent factors associated with limited health literacy.Results: The prevalence of limited health literacy in patients presenting to an urban academic outpatient spine center was 33% (135/405). Unadjusted analysis found that patients who were socioeconomically disadvantaged (eg, unemployed, lower household income, publicly insured and higher SVI) and had more unfavorable social determinant of health features (eg, housing concerns, higher ADI, less years of education, below ninth grade reading level, unmarried) had high rates of limited health literacy. Adjusted regression analysis demonstrated that limited health literacy was independently associated with higher ADI state decile, living less than 10 years at current address, having housing concerns, not being employed, non-native English speaking, having less years of education and below ninth grade reading level.Conclusions: This study found that a substantial portion of the patients presenting to an outpatient spine center have limited health literacy, more so if they are socially disadvantaged. Future efforts should investigate the impact of limited health literacy on access to care, treatment outcomes and health care utilization in orthopedic patients. Neighborhood social vulnerability measures may be a feasible way to identify patients at risk of limited health literacy in clinical practice and offer opportunities for tailored patient care. This may contribute to prioritizing the mitigation of disparities and aid in the development of meaningful interventions to improve health equity in orthopedics. [ABSTRACT FROM AUTHOR]

What's Important: The Social Contract Between Surgeons and Residents Is Still Relevant. [Extracted from the article]

The risk factors for developing proximal junctional failure (PJF) after surgery for adult spinal deformity (ASD) continue to evolve. The lordosis distribution index (LDI) describes the amount of lower arc lordosis (L4-S1) as a fraction of total lumbar lordosis (L1-S1) and has been postulated to influence the outcomes of ASD. The purpose of this study is to determine if the LDI is a risk factor for mechanical failure after ASD. Retrospective review. Adult patients with ASD treated with thoracolumbar fusion (>4 levels, caudal to T9). Demographic variables and surgical data were recorded and radiographic data including proximal junctional angle (PJA), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), pelvic incidence (PI), T1 and T9 spinopelvic inclination (T1-SPI and T9-SPI), and LDI were calculated preoperatively, immediately postoperatively and at 6 months, 1 year and 2 years. Patients were categorized by LDI (severe hypolordosis, moderate hypolordosis, aligned and hyperlordosis) pre- and post-operatively along with the change in LDI between the two time points. Acute PJF (<6 months) was considered the primary outcome variable. Late failure was the secondary outcome measure and defined as PJF after 6 months of the index surgery, fracture of the upper instrumented vertebra (UIV) or UIV+1, rod fracture, non-union and distal junctional failure. There were 187 patients that met the inclusion criteria. Acute PJF occurred in 48 (25.6%) patients. At final follow up, 58 (31.0%) patients underwent surgery for acute PJF or late failure. There was no difference in the prevalence of acute PJF or late failure for patients that were severely hypolordotic (LDI<0.4), moderate hypolordotic (LDI 0.4 –0.49), aligned (LDI 0.5–0.8) or hyperlordotic (LDI>0.8) at the preoperative and immediate postoperative time points. Similarly, there was no difference in acute PJF or late failure when the amount of change in LDI was considered. Univariate cox proportional hazard models demonstrated the number of levels fused, exclusion of the sacrum and/or pelvis during instrumentation, postoperative change in PI-LL and T9-SPI were predictors of early or late failure. The lordosis distribution index is increasingly recognized as a relevant surgical variable in ASD treatment. This study sought to ascertain the association of LDI with mechanical failure. In this cohort of patients, the LDI did not impact the failure rate. However, this study corroborates previously known risk factors for failure including the number of levels fused, excluding the sacrum/pelvis, and amount of PI-LL mismatch correction. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective review of prospective longitudinal data.Objective: To determine health-related quality of life (HRQL) utilities associated with specific ambulatory states in patients with spinal metastases: independent, ambulatory with assistance, and nonambulatory.Summary Of Background Data: It is assumed that HRQL is aligned with ambulatory ability in patients with spinal metastases. Few studies have effectively considered these parameters while also accounting for clinical confounders.Methods: We used prospective longitudinal data from patients treated at one of three tertiary medical centers (2017-2019). HRQL was characterized using the Euroquol-5-dimension (EQ5D) inventory. We performed standardized estimations of HRQL stratified by ambulatory state using generalized linear modeling that accounted for patient age at presentation, biologic sex, follow-up duration, operative or nonoperative management, and repeated measures within the same participant.Results: We evaluated 675 completed EQ5D assessments, with 430 for independent ambulators, 205 for ambulators with assistance, and 40 for nonambulators. The average age of the cohort was 61.5. The most common primary cancer was lung (20%), followed by breast (18%). Forty-one percent of assessments were performed for participants treated surgically. Mortality occurred in 51% of the cohort. The standardized EQ5D utility for patients with spinal metastases and independent ambulatory function was 0.76 (95% confidence interval [CI] 0.74, 0.78). Among those ambulatory with assistance, the standardized EQ5D utility was 0.59 (95% CI 0.57, 0.61). For nonambulators, the standardized EQ5D utility was 0.14 (95% CI 0.09, 0.19).Conclusion: Patients with spinal metastases and independent ambulatory function have an HRQL similar to patients with primary cancers and no spinal involvement. Loss of ambulatory ability leads to a 22% decrease in HRQL for ambulation with assistance and an 82% reduction among nonambulators. Given prior studies demonstrate superior maintenance of ambulatory function with surgery for spinal metastases, our results support surgical consideration to the extent that it is clinically warranted.Level of Evidence: 3. [ABSTRACT FROM AUTHOR]

Background: Geographically based social determinants of health (SDoH) measures are useful in research and policy aimed at addressing health disparities. In the United States, the Area Deprivation Index (ADI), Neighborhood Stress Score (NSS), and Social Vulnerability Index (SVI) are frequently used, but often without a clear reason as to why one is chosen over another. There is limited evidence about how strongly correlated these geographically based SDoH measures are with one another. Further, there is a paucity of research examining their relationship with patient-reported outcome measures (PROMs) in orthopaedic patients. Such insights are important in order to determine whether comparisons of policies and care programs using different geographically based SDoH indices to address health disparities in orthopaedic surgery are appropriate. Questions/purposes: Among new patients seeking care at an orthopaedic surgery clinic, (1) what is the correlation of the NSS, ADI, and SVI with one another? (2) What is the correlation of Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 physical and mental health scores and the NSS, ADI, and SVI? (3) Which geographically based SDoH index or indices are associated with presenting PROMIS Global-10 physical and mental health scores when accounting for common patient-level sociodemographic factors? Methods: New adult orthopaedic patient encounters at clinic sites affiliated with a tertiary referral academic medical center between 2016 and 2021 were identified, and the ADI, NSS, and SVI were determined. Patients also completed the PROMIS Global-10 questionnaire as part of routine care. Overall, a total of 75,335 new patient visits were noted. Of these, 62% (46,966 of 75,335) of new patient visits were excluded because of missing PROMIS Global-10 physical and mental health scores. An additional 2.2% of patients (1685 of 75,335) were excluded because they were missing at least one SDoH index at the time of their visit (for example, if a patient only had a Post Office box listed, the SDoH index could not be determined). This left 35% of the eligible new patient visits (26,684 of 75,335) in our final sample. Though only 35% of possible new patient visits were included, the diversity of these individuals across numerous characteristics and the wide range of sociodemographic status—as measured by the SDoH indices—among included patients supports the generalizability of our sample. The mean age of patients in our sample was 55 ± 18 years and a slight majority were women (54% [14,366 of 26,684]). Among the sample, 16% (4381of 26,684) of patients were of non-White race. The mean PROMIS Global-10 physical and mental health scores were 43.4 ± 9.4 and 49.7 ± 10.1, respectively. Spearman correlation coefficients were calculated among the three SDoH indices and between each SDoH index and PROMIS Global-10 physical and mental health scores. In addition, regression analysis was used to assess the association of each SDoH index with presenting functional and mental health, accounting for key patient characteristics. The strength of the association between each SDoH index and PROMIS Global-10 physical and mental health scores was determined using partial r-squared values. Significance was set at p < 0.05. Results: There was a poor correlation between the ADI and the NSS (ρ = 0.34; p < 0.001). There were good correlations between the ADI and SVI (ρ = 0.43; p < 0.001) and between the NSS and SVI (ρ = 0.59; p < 0.001). There was a poor correlation between the PROMIS Global-10 physical health and NSS (ρ = -0.14; p < 0.001), ADI (ρ = -0.24; p < 0.001), and SVI (ρ = -0.17; p < 0.001). There was a poor correlation between PROMIS Global-10 mental health and NSS (ρ = -0.13; p < 0.001), ADI (ρ = -0.22; p < 0.001), and SVI (ρ = -0.17; p < 0.001). When accounting for key sociodemographic factors, the ADI demonstrated the largest association with presenting physical health (regression coefficient: -0.13 [95% CI -0.14 to -0.12]; p < 0.001) and mental health (regression coefficient: -0.13 [95% CI -0.14 to -0.12]; p < 0.001), as confirmed by the partial r-squared values for each SDoH index (physical health: ADI 0.04 versus SVI 0.02 versus NSS 0.01; mental health: ADI 0.04 versus SVI 0.02 versus NSS 0.01). This finding means that as social deprivation increases, physical and mental health scores decrease, representing poorer health. For further context, an increase in ADI score by approximately 36 and 39 suggests a clinically meaningful (determined using distribution-based minimum clinically important difference estimates of one-half SD of each PROMIS score) worsening of physical and mental health, respectively. Conclusion: Orthopaedic surgeons, policy makers, and other stakeholders looking to address SDoH factors to help alleviate disparities in musculoskeletal care should try to avoid interchanging the ADI, SVI, and NSS. Because the ADI has the largest association between any of the geographically based SDoH indices and presenting physical and mental health, it may allow for easier clinical and policy application. Clinical Relevance: We suggest using the ADI as the geographically based SDoH index in orthopaedic surgery in the United States. Further, we caution against comparing findings in one study that use one geographically based SDoH index to another study's findings that incorporates another geographically based SDoH index. Although the general findings may be the same, the strength of association and clinical relevance could differ and have policy ramifications that are not otherwise appreciated; however, the degree to which this may be true is an area for future inquiry. [ABSTRACT FROM AUTHOR]

Spinal conditions impact health-related quality of life (HRQoL). Patient education and counseling improve HRQoL, yet the effects may be limited for patients with inadequate health literacy (HL). Despite the established relationship between HRQoL and HL in other fields, research in the orthopedic spine population is lacking. To investigate if limited HL results in lower HRQoL and to evaluate factors are associated with HRQoL in patients seen at an outpatient orthopedic spine center. Prospective single-center cross-sectional study. Patients 18 years of age or older seen at a tertiary urban academic hospital- based multi-surgeon outpatient spine center. EQ-5D-5L health-related quality of life (HRQoL) questionnaire, and the Newest Vital Sign (NVS) HL assessment tool. Between October 2022 and February 2023, consecutive English-speaking patients over the age of 18 and new to the outpatient spine clinic were approached for participation in this cross-sectional survey study. Patients completed a sociodemographic survey, EQ-5D-5L HRQoL questionnaire, and Newest Vital Sign (NVS) HL assessment tool. The EQ-5D-5L yields two continuous outcomes: an index score ranging from below 0 to 1 and a visual analog scale (EQ-VAS) score ranging from 0 to 100. The NVS scores were divided into limited (0–3) and adequate (4–6) HL. Multivariate linear regression with purposeful selection of variables was performed to identify independent factors associated with HRQoL. Out of 397 eligible patients, 348 (88%) agreed to participate and were included in statistical analysis. Limited HL was independently associated with lower EQ-5D-5L index scores (B=1.07 [95% CI 1.00–1.15], p=.049. Other factors associated with lower EQ-5D-5L index scores were being obese (BMI≥30), having housing concerns, and being an active smoker. Factors associated with lower EQ-VAS scores were being underweight (BMI<18.5), obese, having housing concerns, and higher updated Charlson comorbidity index (uCCI) scores. Being married was associated with higher EQ-VAS scores. Limited HL is associated with lower EQ-5D-5L index scores in spine patients, indicating lower HRQoL. To effectively apply HL-related interventions in this population, a better understanding of the complex interactions between patient characteristics, social determinants of health, and HRQoL outcomes is required. Further research should focus on interventions to improve HRQoL in patients with limited HL and how to accurately identify these patients. Level II prognostic. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Screening asymptomatic blunt trauma patients for cervical arterial injury is controversial. Vertebral artery injury (VAI) is most commonly associated with cervical spine fracture and some guidelines advocate indiscriminate screening of all cervical spine fractures. PURPOSE To determine whether the addition of computed tomography angiography (CT-A) resulted in a change in management for patients with cervical spine fractures. STUDY DESIGN/SETTING Propensity score matching cohort study. Participants of this study originated from two large academic trauma centers located in a single city. PATIENT SAMPLE Adult patients with acute cervical spine fractures sustained after blunt trauma between 2000 and 2015 were included. Patients with penetrating trauma, neoplasm and prior cervical spine surgery were excluded. There were 3,943 patients screened for inclusion and 2,831 patients eligible. OUTCOME MEASURES Recommendation for a change in management with antithrombosis was the primary outcome measure. Detection of stroke and vertebral artery injury were secondary outcomes. METHODS Demographic data, cervical spine fracture characteristics, utilization of CT-A, presence of vertebral artery injury and outcome were extracted from the medical record. Logistic regression identified factors associated with obtaining a CT-A. Propensity score matching was performed to negate the significant baseline characteristic differences including age, race, medical comorbidities, injury burden, mechanism of injury, upper cervical spine fracture, foramen transversarium involvement, multilevel involvement and associated facet dislocation. This resulted in one cohort receiving CT-A and one cohort that did not, both with 644 patients and equivalent demographic and clinical characteristics. The score matched patients who obtained CT-A with those who obtained CT alone to create two statistically equivalent cohorts. RESULTS In the matched cohorts, average age was 59 years and 57% of each cohort was male. CT-A identified definite or indeterminate VAI in 113 patients and 62 patients had antithrombosis recommended. In the cohort without CT-A, VAI was discovered in 11 patients incidentally through other imaging and eight were recommended antithrombosis. Two patients in the CT-A group had major adverse bleeding events as a result of antithrombosis initiation. There were no preventable strokes in either group. CONCLUSIONS The addition of CT-A increased the detection of VAI and antithrombosis recommendation. There was a high incidence of indeterminate CT-A findings. There were no preventable strokes in either cohort and two major adverse bleeding events as a result of recommended pharmacologic antithrombosis. Non-selective screening is not warranted and should be limited to a high-risk subset of patients. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Case: A 35-year-old man was involved in a motor-vehicle collision and sustained multiple thoracoabdominal and extremity injuries. A high injury burden and a normal neurologic examination contributed to a delay in diagnosing a ligamentous, combined atlanto-occipital dissociation (AOD) and vertical atlantoaxial injury (AAI). Additional imaging revealed the combined injury, and the patient underwent an occipitocervical fusion. Conclusion: To our knowledge, this is the first case of a simultaneous traumatic AOD and AAI without fracture in a neurologically intact patient. Knowledge of reliable and easily applied radiographic relationships is important to expeditiously diagnose potentially lethal yet easily overlooked occipitocervical injuries. [ABSTRACT FROM AUTHOR]

Background: It is well documented that routinely collected patient sociodemographic characteristics (such as race and insurance type) and geography-based social determinants of health (SDoH) measures (for example, the Area Deprivation Index) are associated with health disparities, including symptom severity at presentation. However, the association of patient-level SDoH factors (such as housing status) on musculoskeletal health disparities is not as well documented. Such insight might help with the development of more-targeted interventions to help address health disparities in orthopaedic surgery. Questions/purposes: (1) What percentage of patients presenting for new patient visits in an orthopaedic surgery clinic who were unemployed but seeking work reported transportation issues that could limit their ability to attend a medical appointment or acquire medications, reported trouble paying for medications, and/or had no current housing? (2) Accounting for traditional sociodemographic factors and patient-level SDoH measures, what factors are associated with poorer patient-reported outcome physical health scores at presentation? (3) Accounting for traditional sociodemographic factor patient-level SDoH measures, what factors are associated with poorer patient-reported outcome mental health scores at presentation? Methods: New patient encounters at one Level 1 trauma center clinic visit from March 2018 to December 2020 were identified. Included patients had to meet two criteria: they had completed the Patient-Reported Outcome Measure Information System (PROMIS) Global-10 at their new orthopaedic surgery clinic encounter as part of routine clinical care, and they had visited their primary care physician and completed a series of specific SDoH questions. The SDoH questionnaire was developed in our institution to improve data that drive interventions to address health disparities as part of our accountable care organization work. Over the study period, the SDoH questionnaire was only distributed at primary care provider visits. The SDoH questions focused on transportation, housing, employment, and ability to pay for medications. Because we do not have a way to determine how many patients had both primary care provider office visits and new orthopaedic surgery clinic visits over the study period, we were unable to determine how many patients could have been included; however, 9057 patients were evaluated in this cross-sectional study. The mean age was 61 ± 15 years, and most patients self-reported being of White race (83% [7561 of 9057]). Approximately half the patient sample had commercial insurance (46% [4167 of 9057]). To get a better sense of how this study cohort compared with the overall patient population seen at the participating center during the time in question, we reviewed all new patient clinic encounters (n = 135,223). The demographic information between the full patient sample and our study subgroup appeared similar. Using our study cohort, two multivariable linear regression models were created to determine which traditional metrics (for example, self-reported race or insurance type) and patient-specific SDoH factors (for example, lack of reliable transportation) were associated with worse physical and mental health symptoms (that is, lower PROMIS scores) at new patient encounters. The variance inflation factor was used to assess for multicollinearity. For all analyses, p values < 0.05 designated statistical significance. The concept of minimum clinically important difference (MCID) was used to assess clinical importance. Regression coefficients represent the projected change in PROMIS physical or mental health symptom scores (that is, the dependent variable in our regression analyses) accounting for the other included variables. Thus, a regression coefficient for a given variable at or above a known MCID value suggests a clinical difference between those patients with and without the presence of that given characteristic. In this manuscript, regression coefficients at or above 4.2 (or at and below -4.2) for PROMIS Global Physical Health and at or above 5.1 (or at and below -5.1) for PROMIS Global Mental Health were considered clinically relevant. Results: Among the included patients, 8% (685 of 9057) were unemployed but seeking work, 4% (399 of 9057) reported transportation issues that could limit their ability to attend a medical appointment or acquire medications, 4% (328 of 9057) reported trouble paying for medications, and 2% (181 of 9057) had no current housing. Lack of reliable transportation to attend doctor visits or pick up medications (β = -4.52 [95% CI -5.45 to -3.59]; p < 0.001), trouble paying for medications (β = -4.55 [95% CI -5.55 to -3.54]; p < 0.001), Medicaid insurance (β = -5.81 [95% CI -6.41 to -5.20]; p < 0.001), and workers compensation insurance (β = -5.99 [95% CI -7.65 to -4.34]; p < 0.001) were associated with clinically worse function at presentation. Trouble paying for medications (β = -6.01 [95% CI -7.10 to -4.92]; p < 0.001), Medicaid insurance (β = -5.35 [95% CI -6.00 to -4.69]; p < 0.001), and workers compensation (β = -6.07 [95% CI -7.86 to -4.28]; p < 0.001) were associated with clinically worse mental health at presentation. Conclusion: Although transportation issues and financial hardship were found to be associated with worse presenting physical function and mental health, Medicaid and workers compensation insurance remained associated with worse presenting physical function and mental health as well even after controlling for these more detailed, patient-level SDoH factors. Because of that, interventions to decrease health disparities should focus on not only sociodemographic variables (for example, insurance type) but also tangible patient-specific SDoH characteristics. For example, this may include giving patients taxi vouchers or ride-sharing credits to attend clinic visits for patients demonstrating such a need, initiating financial assistance programs for necessary medications, and/or identifying and connecting certain patient groups with social support services early on in the care cycle. Level of Evidence: Level III, prognostic study. [ABSTRACT FROM AUTHOR]

Limited health literacy has previously been associated with increased health care utilization, worse general health status and self-reported health, and increased mortality. Identifying and accommodating patients with limited health literacy may offer an avenue towards mitigating adverse health outcomes and reduce unnecessary health care expenditure. Due to the challenges associated with implementation of lengthy health literacy assessments, the Brief Health Literacy Screening Instrument was developed. However, to our knowledge, there are no reports on the accuracy of this screening questionnaire, with or without the inclusion of sociodemographic characteristics, when predicting limited health literacy in orthopaedic spine patients. To evaluate the reliability and predictive accuracy of self-reported health literacy screening questions with and without the inclusion of sociodemographic variables in orthopaedic spine patients. Cross-sectional. Patients seen at a tertiary urban academic hospital-based multi-surgeon spine center Brief Health Literacy Screening Instrument (BRIEF), and the Newest Vital Sign (NVS) health literacy assessment tool. Between December 2021 and February 2022, consecutive English-speaking patients over the age of 18 presenting as new patients to an urban, hospital-based outpatient spine clinic were approached for participation. A sociodemographic survey, the BRIEF, and the NVS Health Literacy Assessment Tool were administered verbally. Simple and multivariable logistic regression was utilized to assess the accuracy of each BRIEF question individually, and collectively, at predicting limited health literacy as defined by the NVS. Further regression analysis included sociodemographic variables (age, body mass index, race, ethnicity, highest educational degree, employment status, marital status, annual household income, insurance status, and self-reported health. A total of 262 patients [mean age (years), 57 ± 17] were included in this study. One hundred thirty-four (51%) were male, 223 (85%) were White, and 151 (58%) were married. Patient BRIEF scores were as follows: 23 (9%) limited, 43 (16%) marginal, and 196 (75%) adequate. NVS scores identified 87 (33%) patients with possible limited health literacy. BRIEF items collectively demonstrated fair accuracy in the prediction of limited health literacy (area under the receiver operating characteristic curve, 0.76; 95% CI, 0.70−0.82). Individually, the fourth BRIEF item ("How confident are you in filling out medical forms by yourself?") was the best predictor of limited health literacy (area under the receiver operating characteristic curve, 0.67; 95% CI, 0.60−0.73). The predictive accuracy of the BRIEF items, both individually and collectively, increased with the inclusion of sociodemographic variables within the logistic regression. Specific characteristics independently associated with limited health literacy were self-identified Black race, retired or disabled employment status, single or divorced marital status, high school education or below, and self-reported "poor" health. Limited health literacy has implications for patient outcomes and health care costs. Our results show that the BRIEF questionnaire is a low-cost screening tool that demonstrates fair predictability in determining limited health literacy within a population of spine patients. Self-reported health literacy assessments may be more feasible in daily practice and easier to implement into clinical workflow. [ABSTRACT FROM AUTHOR]

The opioid epidemic is a public health crisis causing significant morbidity, mortality and economic costs nationwide. As a result, discovering alternative forms of pain management is becoming imperative. Medical marijuana is an option for a nonopioid analgesic and is under investigation for potential uses in fields such as oncology and chronic pain, but it is yet to be studied in the surgical setting. Specifically, its effects on bone healing are not fully understood, significantly affecting its potential analgesic efficacy for postorthopaedic surgical care. The goal of this this study is to determine the effect of cannabis derivatives, D9-tetrahydrocannabinol (THC) and cannabidiol (CBD) on bone healing. The effects of marijuana on spinal arthrodesis specifically have yet to be investigated. We hypothesized that THC and CBD will not decrease bone healing in a rat model for spinal fusion. A basic science study utilizing a validated experimental model to assess spinal fusion performed on rats. N/A (Sprague-Dawley rats were used for this basic science study). Manual palpation was done to assess strength of the L4-L5 arthrodesis on all rats. Twelve rats underwent lumbar three-dimensional micro-computed tomography (μCT) imaging and histological analysis. The remaining half were subjected to quantitative polymerase chain reaction (qPCR) analyses which are currently pending. The μCT bone analysis was comprised of quantifying the ratio of bone volume (BV) to total volume (TV) within each volume of interest (VOI), as well as bone mineral density (BMD) and tissue mineral density (TMD) for the corresponding VOI. During follow-up, one animal from the saline and one from the combination group were lost due to wound dehiscence. Kruskal-Wallis test followed by Dunn's multiple comparisons test was performed using GraphPad Prism. Two-tailed values of p < 0.05 were considered statistically significant. Animal procedures were approved by the Institutional Animal Care and Use Committee (IACUC). Twenty-eight adult Sprague-Dawley rats were used for this study. Utilizing allogenic bone graft (4 donor rats), posterolateral inter-transverse lumbar fusion at the L4-L5 level was performed under surgical microscopy. The animals were divided into four groups of 6, each receiving 0.1ml intraperitoneal injections weekly as follows: placebo (saline), 5 mg/kg THC, 5 mg/kg CBD, and a combination of 5 mg/kg THC and 5 mg/kg CBD (combo). Eight weeks postsurgery, animals were euthanized and fusions were assessed. The combination treatment group had the highest fusion rates, with 66.7% demonstrating full fusion and 33.3% demonstrating partial fusion. This was followed by the THC group demonstrating 60% of rats with full fusion, 20% with partial fusion, and 20% with no fusion. Fusion rates were lower in the CBD and saline groups. However, the fusion rates were not significantly different between the treatment groups based on our manual palpation scoring. Callus formation was visually more extensive in THC and Combo treatments on μCT 3D reconstruction images. This observation was confirmed though μCT data, in which bone volume fraction (BV/TV) was significantly higher for the CBD and THC treatment groups compared to the saline treatment group (P <0.05). BMD and TMD values were higher for all cannabis treatment groups compared to the saline treatment group, though not statistically significant. This study preliminarily demonstrates that CBD and THC have no adverse effect on bone regeneration and rate of spinal fusion in rats. Cannabinoids may possess osteoinductive properties which require further investigation. Future larger animal studies should further investigate the effects of cannabinoid receptor agonists on bone healing and formation, with additional exploration of cannabinoid receptor agonists as a potential alternative approach to postoperative analgesia following spinal fusion and other procedures requiring bone formation. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Study Design.: Cross-sectional survey study. Objective.: The aim was to determine if health literacy level is associated with patient-reported outcomes and self-reported health status among patients presenting to an academic outpatient spine center. Summary of Background Data.: Patient reports are critical to assessing symptom severity and treatment success in orthopedic spine patients. Patient-reported outcome measures (PROMs) are important instruments commonly used for this purpose. However, the influence of patient health literacy on PROMs has not yet been given much consideration in spine literature. Materials and Methods.: Consecutive English-speaking patients over the age of 18 years and new to our clinic verbally completed the Newest Vital Sign health literacy assessment tool and a sociodemographic survey, including self-reported health status. In addition, seven Patient-Reported Outcomes Measurement Information System scores were extracted from patient records. Regression modeling was performed with PROMs considered as dependent variables, health literacy level as the primary predictor, and all other factors (age, sex, race, ethnicity, native English speaker, highest educational degree, grade-level reading, marital status, employment status, annual household income, and type of insurance) as covariates. Results.: Among the 318 included patients, 33% had limited health literacy. Adjusted regression analysis demonstrated that patients with limited health literacy had worse PROM scores across all seven domains (Physical Function: P =0.028; Depression: P =0.035; Global Health—Physical: P =0.001; Global Health—Mental: P =0.007; Pain Interference: P =0.036; Pain Intensity: P =0.002; Anxiety: P =0.047). In addition, patients with limited health literacy reported worse self-reported health status (P <0.001). Conclusions.: Spine patients with limited health literacy have worse baseline PROM scores confounders and report worse general health. Further investigations are necessary to elucidate if limited health literacy is a marker or the root cause of these disparities. Findings from this study urge the consideration of patient health literacy when interpreting PROMs as well as the implications for patient assessment and discussion of treatment options. [ABSTRACT FROM AUTHOR]

Rational: Social determinants of health (SDOH) are being considered more frequently when providing orthopaedic care due to their impact on treatment outcomes. Simultaneously, prognostic machine learning (ML) models that facilitate clinical decision making have become popular tools in the field of orthopaedic surgery. When ML‐driven tools are developed, it is important that the perpetuation of potential disparities is minimized. One approach is to consider SDOH during model development. To date, it remains unclear whether and how existing prognostic ML models for orthopaedic outcomes consider SDOH variables. Objective: To investigate whether prognostic ML models for orthopaedic surgery outcomes account for SDOH, and to what extent SDOH variables are included in the final models. Methods: A systematic search was conducted in PubMed, Embase and Cochrane for studies published up to 17 November 2020. Two reviewers independently extracted SDOH features using the PROGRESS+ framework (place of residence, race/ethnicity, Occupation, gender/sex, religion, education, social capital, socioeconomic status, 'Plus+' age, disability, and sexual orientation). Results: The search yielded 7138 studies, of which 59 met the inclusion criteria. Across all studies, 96% (57/59) considered at least one PROGRESS+ factor during development. The most common factors were age (95%; 56/59) and gender/sex (96%; 57/59). Differential effect analyses, such as subgroup analysis, covariate adjustment, and baseline comparison, were rarely reported (10%; 6/59). The majority of models included age (92%; 54/59) and gender/sex (69%; 41/59) as final input variables. However, factors such as insurance status (7%; 4/59), marital status (7%; 4/59) and income (3%; 2/59) were seldom included. Conclusion: The current level of reporting and consideration of SDOH during the development of prognostic ML models for orthopaedic outcomes is limited. Healthcare providers should be critical of the models they consider using and knowledgeable regarding the quality of model development, such as adherence to recognized methodological standards. Future efforts should aim to avoid bias and disparities when developing ML‐driven applications for orthopaedics. [ABSTRACT FROM AUTHOR]

Background Context: Historically, spine surgeons used expected postoperative survival of 3-months to help select candidates for operative intervention in spinal metastasis. However, this cutoff has been challenged by the development of minimally invasive techniques, novel biologics, and advanced radiotherapy. Recent studies have suggested that a life expectancy of 6 weeks may be enough to achieve significant improvements in postoperative health-related quality of life.Purpose: The purpose of this study was to develop a model capable of predicting 6-week mortality in patients with spinal metastases treated with radiation or surgery.Study Design/setting: A retrospective review was conducted at five large tertiary centers in the United States and Taiwan.Patient Sample: The development cohort consisted of 3,001 patients undergoing radiotherapy and/or surgery for spinal metastases from one institution. The validation institutional cohort consisted of 1,303 patients from four independent, external institutions.Outcome Measures: The primary outcome was 6-week mortality.Methods: Five models were considered to predict 6-week mortality, and the model with the best performance across discrimination, calibration, decision-curve analysis, and overall performance was integrated into an open access web-based application.Results: The most important variables for prediction of 6-week mortality were albumin, primary tumor histology, absolute lymphocyte, three or more spine metastasis, and ECOG score. The elastic-net penalized logistic model was chosen as the best performing model with AUC 0.84 on evaluation in the independent testing set. On external validation in the 1,303 patients from the four independent institutions, the model retained good discriminative ability with an area under the curve of 0.81. The model is available here: https://sorg-apps.shinyapps.io/spinemetssurvival/.Conclusions: While this study does not advocate for the use of a 6-week life expectancy as criteria for considering operative management, the algorithm developed and externally validated in this study may be helpful for preoperative planning, multidisciplinary management, and shared decision-making in spinal metastasis patients with shorter life expectancy. [ABSTRACT FROM AUTHOR]

Background: Incidental durotomy is an intraoperative complication in spine surgery that can lead to postoperative complications, increased length of stay, and higher healthcare costs. Natural language processing (NLP) is an artificial intelligence method that assists in understanding free-text notes that may be useful in the automated surveillance of adverse events in orthopaedic surgery. A previously developed NLP algorithm is highly accurate in the detection of incidental durotomy on internal validation and external validation in an independent cohort from the same country. External validation in a cohort with linguistic differences is required to assess the transportability of the developed algorithm, referred to geographical validation. Ideally, the performance of a prediction model, the NLP algorithm, is constant across geographic regions to ensure reproducibility and model validity.Question/purpose: Can we geographically validate an NLP algorithm for the automated detection of incidental durotomy across three independent cohorts from two continents?Methods: Patients 18 years or older undergoing a primary procedure of (thoraco)lumbar spine surgery were included. In Massachusetts, between January 2000 and June 2018, 1000 patients were included from two academic and three community medical centers. In Maryland, between July 2016 and November 2018, 1279 patients were included from one academic center, and in Australia, between January 2010 and December 2019, 944 patients were included from one academic center. The authors retrospectively studied the free-text operative notes of included patients for the primary outcome that was defined as intraoperative durotomy. Incidental durotomy occurred in 9% (93 of 1000), 8% (108 of 1279), and 6% (58 of 944) of the patients, respectively, in the Massachusetts, Maryland, and Australia cohorts. No missing reports were observed. Three datasets (Massachusetts, Australian, and combined Massachusetts and Australian) were divided into training and holdout test sets in an 80:20 ratio. An extreme gradient boosting (an efficient and flexible tree-based algorithm) NLP algorithm was individually trained on each training set, and the performance of the three NLP algorithms (respectively American, Australian, and combined) was assessed by discrimination via area under the receiver operating characteristic curves (AUC-ROC; this measures the model's ability to distinguish patients who obtained the outcomes from those who did not), calibration metrics (which plot the predicted and the observed probabilities) and Brier score (a composite of discrimination and calibration). In addition, the sensitivity (true positives, recall), specificity (true negatives), positive predictive value (also known as precision), negative predictive value, F1-score (composite of precision and recall), positive likelihood ratio, and negative likelihood ratio were calculated.Results: The combined NLP algorithm (the combined Massachusetts and Australian data) achieved excellent performance on independent testing data from Australia (AUC-ROC 0.97 [95% confidence interval 0.87 to 0.99]), Massachusetts (AUC-ROC 0.99 [95% CI 0.80 to 0.99]) and Maryland (AUC-ROC 0.95 [95% CI 0.93 to 0.97]). The NLP developed based on the Massachusetts cohort had excellent performance in the Maryland cohort (AUC-ROC 0.97 [95% CI 0.95 to 0.99]) but worse performance in the Australian cohort (AUC-ROC 0.74 [95% CI 0.70 to 0.77]).Conclusion: We demonstrated the clinical utility and reproducibility of an NLP algorithm with combined datasets retaining excellent performance in individual countries relative to algorithms developed in the same country alone for detection of incidental durotomy. Further multi-institutional, international collaborations can facilitate the creation of universal NLP algorithms that improve the quality and safety of orthopaedic surgery globally. The combined NLP algorithm has been incorporated into a freely accessible web application that can be found at https://sorg-apps.shinyapps.io/nlp_incidental_durotomy/ . Clinicians and researchers can use the tool to help incorporate the model in evaluating spine registries or quality and safety departments to automate detection of incidental durotomy and optimize prevention efforts.Level Of Evidence: Level III, diagnostic study. [ABSTRACT FROM AUTHOR]

Background: Patient-reported outcome measures (PROMs), including the Patient-reported Outcomes Measurement Information System (PROMIS), are increasingly used to measure healthcare value. The minimum clinically important difference (MCID) is a metric that helps clinicians determine whether a statistically detectable improvement in a PROM after surgical care is likely to be large enough to be important to a patient or to justify an intervention that carries risk and cost. There are two major categories of MCID calculation methods, anchor-based and distribution-based. This variability, coupled with heterogeneous surgical cohorts used for existing MCID values, limits their application to clinical care.Questions/purposes: In our study, we sought (1) to determine MCID thresholds and attainment percentages for PROMIS after common orthopaedic procedures using distribution-based methods, (2) to use anchor-based MCID values from published studies as a comparison, and (3) to compare MCID attainment percentages using PROMIS scores to other validated outcomes tools such as the Hip Disability and Osteoarthritis Outcome Score (HOOS) and Knee Disability and Osteoarthritis Outcome Score (KOOS).Methods: This was a retrospective study at two academic medical centers and three community hospitals. The inclusion criteria for this study were patients who were age 18 years or older and who underwent elective THA for osteoarthritis, TKA for osteoarthritis, one-level posterior lumbar fusion for lumbar spinal stenosis or spondylolisthesis, anatomic total shoulder arthroplasty or reverse total shoulder arthroplasty for glenohumeral arthritis or rotator cuff arthropathy, arthroscopic anterior cruciate ligament reconstruction, arthroscopic partial meniscectomy, or arthroscopic rotator cuff repair. This yielded 14,003 patients. Patients undergoing revision operations or surgery for nondegenerative pathologies and patients without preoperative PROMs assessments were excluded, leaving 9925 patients who completed preoperative PROMIS assessments and 9478 who completed other preoperative validated outcomes tools (HOOS, KOOS, numerical rating scale for leg pain, numerical rating scale for back pain, and QuickDASH). Approximately 66% (6529 of 9925) of patients had postoperative PROMIS scores (Physical Function, Mental Health, Pain Intensity, Pain Interference, and Upper Extremity) and were included for analysis. PROMIS scores are population normalized with a mean score of 50 ± 10, with most scores falling between 30 to 70. Approximately 74% (7007 of 9478) of patients had postoperative historical assessment scores and were included for analysis. The proportion who reached the MCID was calculated for each procedure cohort at 6 months of follow-up using distribution-based MCID methods, which included a fraction of the SD (1/2 or 1/3 SD) and minimum detectable change (MDC) using statistical significance (such as the MDC 90 from p < 0.1). Previously published anchor-based MCID thresholds from similar procedure cohorts and analogous PROMs were used to calculate the proportion reaching MCID.Results: Within a given distribution-based method, MCID thresholds for PROMIS assessments were similar across multiple procedures. The MCID threshold ranged between 3.4 and 4.5 points across all procedures using the 1/2 SD method. Except for meniscectomy (3.5 points), the anchor-based PROMIS MCID thresholds (range 4.5 to 8.1 points) were higher than the SD distribution-based MCID values (2.3 to 4.5 points). The difference in MCID thresholds based on the calculation method led to a similar trend in MCID attainment. Using THA as an example, MCID attainment using PROMIS was achieved by 76% of patients using an anchor-based threshold of 7.9 points. However, 82% of THA patients attained MCID using the MDC 95 method (6.1 points), and 88% reached MCID using the 1/2 SD method (3.9 points). Using the HOOS metric (scaled from 0 to 100), 86% of THA patients reached the anchor-based MCID threshold (17.5 points). However, 91% of THA patients attained the MCID using the MDC 90 method (12.5 points), and 93% reached MCID using the 1/2 SD method (8.4 points). In general, the proportion of patients reaching MCID was lower for PROMIS than for other validated outcomes tools; for example, with the 1/2 SD method, 72% of patients who underwent arthroscopic partial meniscectomy reached the MCID on PROMIS Physical Function compared with 86% on KOOS.Conclusion: MCID calculations can provide clinical correlation for PROM scores interpretation. The PROMIS form is increasingly used because of its generalizability across diagnoses. However, we found lower proportions of MCID attainment using PROMIS scores compared with historical PROMs. By using historical proportions of attainment on common orthopaedic procedures and a spectrum of MCID calculation techniques, the PROMIS MCID benchmarks are realizable for common orthopaedic procedures. For clinical practices that routinely collect PROMIS scores in the clinical setting, these results can be used by individual surgeons to evaluate personal practice trends and by healthcare systems to quantify whether clinical care initiatives result in meaningful differences. Furthermore, these MCID thresholds can be used by researchers conducting retrospective outcomes research with PROMIS.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Cervical sagittal alignment (CSA) parameters are helpful in determining the surgical technique used to treat cervical spondylotic myelopathy. Upright lateral radiographs are routinely used to measure CSA parameters, but obtaining adequate imaging is difficult. Utilizing magnetic resonance imaging (MRI) to evaluate sagittal parameters has been explored; however, the impact of positional changes on these parameters has not been elucidated. To evaluate CSA parameter measurement reliability and correlation between XR and MRI modalities in patients undergoing posterior decompressive procedures for cervical spondylotic myelopathy. Retrospective cohort study. We evaluated adult patients who had undergone laminoplasty or laminectomy and fusion for cervical spondylotic myelopathy between 2017 and 2019 and who had cervical spine XR and MRI within a 6-month timespan of one another. Outcomes of interest included intra- and interobserver reliability assessment of C2-C7 sagittal angle, C2-C7 sagittal vertical axis (SVA), and T1 tilt measurements as well as correlations in these parameters between imaging modalities. Two clinicians completed two independent rounds of C2-C7 sagittal angle, C2-C7 sagittal vertical axis (SVA), and T1 tilt measurements; intra- and interobserver reliability were assessed by intraclass correlation coefficient (ICC). Correlations between imaging modalities were analyzed using parametric and nonparametric statistical tests. Intra- and interobserver reliabilities were highly correlated with correlations greater than 0.85 across all permutations; ICCs were highest with MRI measurements. The C2-C7 sagittal angle was highly correlated between XR and MRI at 0.76 with no significant difference (p = 0.46). Weaker correlations existed for C2-C7 SVA (0.48) and T1 tilt (0.62) measurements with significant differences observed in the mean values between the two imaging modalities (p < 0.01). The C2-C7 sagittal angle is highly correlated and not significantly different between upright XR and supine MR images. However, cervical SVA and T1 tilt change with patient position. As MRI does not accurately reflect the CSA in the upright position, upright lateral radiographs should be obtained to assess global sagittal alignment when planning posterior based cervical fusions. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Study Design: Prospective observational study.Objective: We present the natural history, including survival and function, among participants in the prospective observational study of spinal metastases treatment investigation.Summary Of Background Data: Surgical treatment has been touted as a means to preserve functional independence, quality of life, and survival. Nearly all prior investigations have been limited by retrospective design and relatively short-periods of post-treatment surveillance.Methods: This natural history study was conducted using the records of patients who were enrolled in the prospective observational study of spinal metastases treatment study (2017-2019). Eligible participants were 18 or older and presenting for treatment of spinal metastatic disease. Patients were followed at predetermined intervals (1, 3, 6, 12, and 24-mo) following treatment. We conducted cox proportional hazard regression analysis adjusting for confounders including age, biologic sex, number of comorbidities, type of metastatic lesion, neurologic symptoms at presentation, number of metastases involving the vertebral body, vertebral body collapse, New England Spinal Metastasis Score (NESMS) at presentation, and treatment strategy.Results: We included 202 patients. Twenty-three percent of the population had died by 3 months following treatment initiation, 51% by 1 year, and 70% at 2 years. There was no significant difference in survival between patients treated operatively and nonoperatively (P = 0.16). No significant difference in HRQL between groups was appreciated beyond 3 months following treatment initiation. NESMS at presentation (scores of 0 [HR 5.61; 95% CI 2.83, 11.13] and 1 [HR 3.00; 95% CI 1.60, 5.63]) was significantly associated with mortality.Conclusion: We found that patients treated operatively and nonoperatively for spinal metastases benefitted from treatment in terms of HRQL. Two-year mortality for the cohort as a whole was 70%. When prognosticating survival, the NESMS appears to be an effective utility, particularly among patients with scores of 0 or 1.Level of Evidence: 2. [ABSTRACT FROM AUTHOR]

Background Context: Preoperative methicillin-resistant Staphylococcus aureus (MRSA) testing and decolonization has demonstrated success for arthroplasty patients in surgical site infections (SSIs) prevention. Spine surgery, however, has seen varied results.Purpose: The purpose of this study was to determine the impact of nasal MRSA testing and operative debridement rates on surgical site infection after primary lumbar fusion.Study Design/setting: Retrospective cohort study and/or Consolidated medical enterprise PATIENT SAMPLE: Adult patients undergoing primary instrumented lumbar fusions from January 2015 to December 2019 were reviewed.Outcome Measures: The primary outcome was incision and drainage performed in the operating room within 90 days of surgery.Methods: MRSA testing <90-day's before surgery, mupirocin prescription <30-day's before surgery, perioperative antibiotics, and Elixhauser comorbidity index were collected for each subject. Bivariate analysis used Wilcoxon rank-sum testing and logistic regression modeling Multivariable logistic regression modeling assessed for associations with MRSA testing, intravenous vancomycin use, and I&D rate.Results: The study included 1,884 patients for analysis, with mean age of 63.1 (SE 0.3) and BMI 29.5 (SE 0.1). MRSA testing was performed in 755 patients (40.1%) and was more likely to be performed in patients with lower Elixhauser index scores (OR 0.98, 95% CI 0.96-0.99, p=.021) on multivariable analysis. Vancomycin use increased significantly over time (OR 1.49 and/or year, 95% CI 1.3-1.8, p<.001) despite no change in mupirocin or I&D rates. MRSA testing, mupirocin prescriptions, perioperative parenteral vancomycin use, and intrawound vancomycin powder use had no impact on I&D rates. I&D risk was associated with higher BMI (OR 1.06, 95% CI 1.02-1.12, p=.009) and higher number of blood product units transfused (OR 1.23, 95% CI 1.03-1.46, p=.022).Conclusions: The present study demonstrates no impact on surgical I&D rates from the use of preoperative MRSA testing. Increased BMI and transfusions were associated with operative I&D rates for surgical site infection. As a result of the hospital directive, vancomycin use increased over time with no associated change in infection rates, underscoring the need for focused interventions, and engagement with antibiotic stewardship programs. [ABSTRACT FROM AUTHOR]

Background Context: We developed the New England Spinal Metastasis Score (NESMS) as a simple, informative, scoring scheme that could be applied to both operative and non-operative patients. The performance of the NESMS to other legacy scoring systems has not previously been compared using appropriately powered, prospectively collected, longitudinal data.Purpose: To compare the predictive capacity of the NESMS to the Tokuhashi, Tomita and Spinal Instability Neoplastic Score (SINS) in a prospective cohort, where all scores were assigned at the time of baseline enrollment.Patient Sample: We enrolled 202 patients with spinal metastases who met inclusion criteria between 2017-2019.Outcome Measures: One-year survival (primary); 3-month mortality and ambulatory function at 3- and 6-months were considered secondarily.Methods: All prognostic scores were assigned based on enrollment data, which was also assigned as time-zero. Patients were followed until death or survival at 365 days after enrollment. Survival was assessed using Kaplan-Meier curves and score performance was determined via logistic regression testing and observed to expected plots. The discriminative capacity (c-statistic) of the scoring measures were compared via the z-score.Results: When comparing the discriminative capacity of the predictive scores, the NESMS had the highest c-statistic (0.79), followed by the Tomita (0.69), the Tokuhashi (0.67) and the SINS (0.54). The discriminative capacity of the NESMS was significantly greater (p-value range: 0.02 to <0.001) than any of the other predictive tools. The NESMS was also able to inform independent ambulatory function at 3- and 6-months, a function that was only uniformly replicated by the Tokuhashi score.Conclusions: The results of this prospective validation study indicate that the NESMS was able to differentiate survival to a significantly higher degree than the Tokuhashi, Tomita and SINS. We believe that these findings endorse the utilization of the NESMS as a prognostic tool capable of informing care for patients with spinal metastases. [ABSTRACT FROM AUTHOR]

➤: As the Patient-Reported Outcomes Measurement Information System (PROMIS) is increasingly utilized in orthopaedic research and clinical practice, there is not a consensus regarding the minimum clinically important difference (MCID) calculation.➤: The varied MCID calculation methods can lead to a range of possible values, which limits the translatability of research efforts.➤: The completion rate and follow-up period also influence MCID values and should be reported alongside study results. [ABSTRACT FROM AUTHOR]

Background: Intraoperative vascular injury (VI) may be an unavoidable complication of anterior lumbar spine surgery; however, vascular injury has implications for quality and safety reporting as this intraoperative complication may result in serious bleeding, thrombosis, and postoperative stricture.Purpose: The purpose of this study was to (1) develop machine learning algorithms for preoperative prediction of VI and (2) develop natural language processing (NLP) algorithms for automated surveillance of intraoperative VI from free-text operative notes.Patient Sample: Adult patients, 18 years or age or older, undergoing anterior lumbar spine surgery at two academic and three community medical centers were included in this analysis.Outcome Measures: The primary outcome was unintended VI during anterior lumbar spine surgery.Methods: Manual review of free-text operative notes was used to identify patients who had unintended VI. The available population was split into training and testing cohorts. Five machine learning algorithms were developed for preoperative prediction of VI. An NLP algorithm was trained for automated detection of intraoperative VI from free-text operative notes. Performance of the NLP algorithm was compared to current procedural terminology and international classification of diseases codes.Results: In all, 1035 patients underwent anterior lumbar spine surgery and the rate of intraoperative VI was 7.2% (n=75). Variables used for preoperative prediction of VI were age, male sex, body mass index, diabetes, L4-L5 exposure, and surgery for infection (discitis, osteomyelitis). The best performing machine learning algorithm achieved c-statistic of 0.73 for preoperative prediction of VI (https://sorg-apps.shinyapps.io/lumbar_vascular_injury/). For automated detection of intraoperative VI from free-text notes, the NLP algorithm achieved c-statistic of 0.92. The NLP algorithm identified 18 of the 21 patients (sensitivity 0.86) who had a VI whereas current procedural terminologyand international classification of diseases codes identified 6 of the 21 (sensitivity 0.29) patients. At this threshold, the NLP algorithm had a specificity of 0.93, negative predictive value of 0.99, positive predictive value of 0.51, and F1-score of 0.64.Conclusion: Relying on administrative procedural and diagnosis codes may underestimate the rate of unintended intraoperative VI in anterior lumbar spine surgery. External and prospective validation of the algorithms presented here may improve quality and safety reporting. [ABSTRACT FROM AUTHOR]

Background Content: Cervical laminoplasty (LP) and laminectomy and fusion (LF) are commonly used surgical techniques for cervical spondylotic myelopathy (CSM). Several recent studies have demonstrated superior perioperative metrics and decreased overall costs with LP, yet LF is performed far more often in the United States.Purpose: To determine the percentage of patients with CSM who are radiographically candidates for LP.Study Design: Retrospective comparative cohort study.Patient Sample: Patients >18 years old who underwent LF or LP for CSM at 2 large academic institutions from 2017 to 2019.Outcome Measures: Candidacy for LP based on radiographic criteria.Methods: Radiographs were assessed by 2 spine surgeons not involved in the care of the patients to determine the C2-C7 Cobb angle and the presence and extent of cervical instability. Patients with kyphosis >13°, > 3.5 mm of listhesis on static imaging, or > 2.5 mm of motion on flexion-extension or standing-supine films were not considered candidates for LP. Intraclass coefficient (ICC) was calculated to assess the interobserver reliability of angular measurements and the presence of instability. The percentage of patients for whom LP was contraindicated was calculated.Results: One hundred eight patients underwent LF while 142 underwent LP. Of the 108 patients who underwent LF, 79.6% were radiographically deemed candidates for LP, as were all 142 patients who underwent LP. The ICC for C2-C7 alignment was 0.90; there was 97% agreement with respect to the presence of instability.Conclusions: In 250 patients with CSM, 228 (91.2%) were radiographically candidates for LP. These data suggest that LP may be an underutilized procedure for the treatment for CSM. [ABSTRACT FROM AUTHOR]

Background Context: Patient-Reported Outcome Measurement Information System (PROMIS) scores are increasingly utilized in clinical care. However, it is unclear if PROMIS can discriminate surgeon performance on an individual level.Purpose: The purpose of this study was to examine surgeon-level variance in rates of achieving minimal clinically important difference (MCID) after lumbar decompression.Patient Sample: This is a prospective, observational cohort study performed across a healthcare enterprise (two academic medical centers and three community centers). Patients 18 years or older undergoing one- to two-level primary decompression for lumbar disc herniation (LDH) or lumbar spinal stenosis (LSS) were included.Outcome Measures: The primary outcome was achievement of MCID, using a distribution-based method, on paired PROMIS physical function scores.Methods: Descriptive statistics were generated to examine the baseline characteristics of the study cohort. Bivariate analyses were used to examine the impact of surgeon-level variance on rates of MCID. Multivariable analyses were used to examine the risk-adjusted impact of surgeon-level variance on rates of MCID.Results: Overall, 636 patients treated by nine surgeons were included. The median patient age was 58 [interquartile range (IQR): 46-70] and 62.3% (n=396) were female. Among all patients, 56.9% (n=362) underwent surgery for LDH. The overall rate of achieving MCID was 75.8% (n=482). Of the surgeons, the median years in practice were 12 (range 4-31) and 55.6% (n=5) were in academic practice settings. On bivariate analysis, patients treated by one of the surgeons had lower rates of achieving MICD (odds ratio=0.37, 95% confidence interval: 0.15-0.91, p=.03). However, on multivariable analysis adjusting for operative indication (LDH vs. LSS), body mass index, number of comorbidities, percent unemployment in patient zip code, and preoperative PROMIS physical function scores, all surgeons were equally likely to obtain MCID.Conclusions: In this cohort, variance in PROMIS scores after primary lumbar decompression is influenced by patient-related factors and not by individual surgeon. Adequate risk adjustment is needed if ascertaining clinical improvement on an individual surgeon basis.Level Of Evidence: 2. [ABSTRACT FROM AUTHOR]

Background: The ability to preoperatively predict which patients will achieve a minimal clinically important difference (MCID) after lumbar spine decompression surgery can help determine the appropriateness and timing of surgery. Patient-Reported Outcome Measurement Information System (PROMIS) scores are an increasingly popular outcome instrument.Purpose: The purpose of this study was to develop algorithms predictive of achieving MCID after primary lumbar decompression surgery.Patient Sample: This was a retrospective study at two academic medical centers and three community medical centers including adult patients 18 years or older undergoing one or two level posterior decompression for lumbar disc herniation or lumbar spinal stenosis between January 1, 2016 and April 1, 2019.Outcome Measures: The primary outcome, MCID, was defined using distribution-based methods as one half the standard deviation of postoperative patient-reported outcomes (PROMIS physical function, pain interference, pain intensity).Methods: Five machine learning algorithms were developed to predict MCID on these surveys and assessed by discrimination, calibration, Brier score, and decision curve analysis. The final model was incorporated into an open access digital application.Results: Overall, 906 patients completed at least one PROMs survey in the 90 days before surgery and at least one PROMs survey in the year after surgery. Attainment of MCID during the study period by PROMIS instrument was 74.3% for physical function, 75.8% for pain interference, and 79.2% for pain intensity. Factors identified for preoperative prediction of MCID attainment on these outcomes included preoperative PROs, percent unemployment in neighborhood of residence, comorbidities, body mass index, private insurance, preoperative opioid use, surgery for disc herniation, and federal poverty level in neighborhood of residence. The discrimination (c-statistic) of the final algorithms for these outcomes was 0.79 for physical function, 0.74 for pain interference, and 0.69 for pain intensity with good calibration. The open access digital application for these algorithms can be found here: https://sorg-apps.shinyapps.io/promis_pld_mcid/ CONCLUSION: Lower preoperative PROMIS scores, fewer comorbidities, and certain sociodemographic factors increase the likelihood of achieving MCID for PROMIS after lumbar spine decompression. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to identify modifiable factors associated with research activity among residents working in orthopedic surgery and traumatology. Methods: Residents at 796 university-affiliated hospitals in Austria, Germany, and Switzerland were invited to participate. The online survey consisted of questions that ascertained 13 modifiable and 17 non-modifiable factors associated with the residents' current research activities. Responses of 129 residents were analyzed. Univariate linear regression was used to determine the association of individual factors with the current research activity (hours per week). The impact of significant non-modifiable factors (with unadjusted p values < 0.05) was controlled for using multivariate linear regression. Results: The univariate analysis demonstrated six non-modifiable factors that were significantly associated with the current research activity: a University hospital setting (p < 0.001), an A-level hospital setting (p = 0.024), Swiss residents (p = 0.0012), the completion of a dedicated research year (p = 0.007), female gender (p = 0.016), and the department's size (p = 0.048). Multivariate regression demonstrated that the number of protected research days per year (p < 0.029) and the percentage of protected days, that were known 1 week before (p < 0.001) or the day before (p < 0.001), were significantly associated with a higher research activity. Conclusions: As hypothesized, more frequent and predictable protected research days were associated with higher research activity among residents in orthopedic surgery and traumatology. Level of evidence: III. [ABSTRACT FROM AUTHOR]

Background Context: The New England Spinal Metastasis Score (NESMS) was proposed as an intuitive and accessible prognostic tool for predicting survival in patients with spinal metastases. We designed an appropriately powered, prospective, longitudinal investigation to validate the NESMS.Purpose: To prospectively validate the NESMS.Study Design: Prospective longitudinal observational cohort study.Patient Sample: Patients, aged 18 and older, presenting for treatment with spinal metastatic disease.Outcome Measures: One-year mortality (primary); 6-month mortality and mortality at any time point following enrollment (secondary).Methods: The date of enrollment was set as time zero for all patients. The NESMS was assigned based on data collected at the time of enrollment. Patients were prospectively followed to one of two predetermined end-points: death, or survival at 365 days following enrollment. Survival was visually assessed with Kaplan-Meier curves and then analyzed using multivariable logistic regression, followed by Bayesian regression to assess for robustness of point estimates and 95% confidence intervals (CI).Results: This study included 180 patients enrolled between 2017 and 2018. Mortality within 1-year occurred in 56% of the cohort. Using NESMS 3 as the referent, those with a score of 2 had significantly greater odds of mortality (odds ratio 7.04; 95% CI 2.47, 20.08), as did those with a score of 1 (odds ratio 31.30; 95% CI 8.82, 111.04). A NESMS score of 0 was associated with perfect prediction, as 100% of individuals with this score were deceased at 1-year. Similar determinations were encountered for mortality at 6-months and overall.Conclusions: This study validates the NESMS and demonstrates its utility in prognosticating survival for patients with spinal metastatic disease, irrespective of selected treatment strategy. This is the first study to prospectively validate a prognostic utility for patients with spinal metastases. The NESMS can be directly applied to patient care, hospital-based practice and health-care policy. [ABSTRACT FROM AUTHOR]

Background Context: Laminectomy with fusion (LF) and laminoplasty (LP) are commonly used to treat cervical spondylotic myelopathy (CSM). The decision regarding which procedure to perform is largely a matter of surgeon's preference, while financial implications are rarely considered.Purpose: We aimed to better understand the financial considerations of LF compared to LP in the treatment of CSM.Study Design: Retrospective comparative study.Patient Sample: Adult patients, 18 years of age or older, who had undergone LF or LP for CSM from 2017 to 2019 at 2 large academic centers were included. Patients who had undergone previous cervical spine surgery or procedures that extended above C2 or below T2 were excluded.Outcome Measures: The primary outcome was defined as the total cost of the procedure, which was calculated as the sum of the implant and non-implant supply costs.Methods: Patient demographics, surgical parameters, including estimated blood loss and operative time, and length of stay were collected. Operating room material - both implant and non-implant - cost data was also obtained. Variables were analyzed individually as well as after adjustment based on the number of operative levels involved. Statistical analysis was performed using either Student t test with unequal variance or Wilcoxon rank sum test for continuous variables and chi-squared analysis for categorical variables.Results: Two hundred fifty patients were identified who met inclusion criteria. There was no statistical difference in the mean age at time of surgery (p=.25), gender distribution (p=.33), or re-operation rate between the LF and LP groups (p=.39). Overall, operative time was similar between the LF (165.7 ± 61.9 min) and LP (173.8 ± 58.2 min) groups (p=.29), but the LP cohort had a shorter length of stay at 3.8 ± 2.7 days compared to the LF cohort at 4.8 ± 3.7 days. Implant costs in the LF group were significantly more at $6,204.94 ± $1426.41 compared to LP implant costs at $1994.39 ± $643.09. Mean total costs of LP were significantly less at $2,859.08 ± $784.19 compared to LF total costs of $6,983.16 ± $1,589.17. Furthermore, when adjusted for the number of operative levels, LP remained significantly less costly at $766.12 ± $213.64 per level while LF cost $1,789.05 ± $486.66 per operative level. Additional subgroup analysis limiting the cohorts to patients with either three or four involved vertebral levels demonstrated nearly identical cost savings with LP as compared to LF.Conclusions: This study demonstrates that LF is on average at least 2.4 times the total operative supply cost of LP and at least 2.3 times the operative supply cost of LP when adjusted for the number of operative levels. In patients deemed appropriate for either LP or LF, these data may be incorporated into decision-making for the treatment of CSM. [ABSTRACT FROM AUTHOR]

Background: Surgical site infections are a major driver of morbidity and increased costs in the postoperative period after spine surgery. Current tools for surveillance of these adverse events rely on prospective clinical tracking, manual retrospective chart review, or administrative procedural and diagnosis codes.Purpose: The purpose of this study was to develop natural language processing (NLP) algorithms for automated reporting of postoperative wound infection requiring reoperation after lumbar discectomy.Patient Sample: Adult patients undergoing discectomy at two academic and three community medical centers between January 1, 2000 and July 31, 2019 for lumbar disc herniation.Outcome Measures: Reoperation for wound infection within 90 days after surgery METHODS: Free-text notes of patients who underwent surgery from January 1, 2000 to December 31, 2015 were used for algorithm training. Free-text notes of patients who underwent surgery after January 1, 2016 were used for algorithm testing. Manual chart review was used to label which patients had reoperation for wound infection. An extreme gradient-boosting NLP algorithm was developed to detect reoperation for postoperative wound infection.Results: Overall, 5,860 patients were included in this study and 62 (1.1%) had a reoperation for wound infection. In patients who underwent surgery after January 1, 2016 (n=1,377), the NLP algorithm detected 15 of the 16 patients (sensitivity=0.94) who had reoperation for infection. In comparison, current procedural terminology and international classification of disease codes detected 12 of these 16 patients (sensitivity=0.75). At a threshold of 0.05, the NLP algorithm had positive predictive value of 0.83 and F1-score of 0.88.Conclusion: Temporal validation of the algorithm developed in this study demonstrates a proof-of-concept application of NLP for automated reporting of adverse events after spine surgery. Adapting this methodology for other procedures and outcomes in spine and orthopedics has the potential to dramatically improve and automatize quality and safety reporting. [ABSTRACT FROM AUTHOR]

Importance: Preoperative determination of the potential for postoperative opioid dependence in previously naïve patients undergoing elective spine surgery may facilitate targeted interventions.Objective: The purpose of this study was to develop supervised machine learning algorithms for preoperative prediction of prolonged opioid prescription use in opioid-naïve patients following lumbar spine surgery.Design: Retrospective review of clinical registry data. Variables considered for prediction included demographics, insurance status, preoperative medications, surgical factors, laboratory values, comorbidities, and neighborhood characteristics. Five supervised machine learning algorithms were developed and assessed by discrimination, calibration, Brier score, and decision curve analysis.Setting: One healthcare entity (two academic medical centers, three community hospitals), 2000 to 2018.Participants: Opioid-naïve patients undergoing decompression and/or fusion for lumbar disk herniation, stenosis, and spondylolisthesis.Main Outcome: Sustained prescription opioid use exceeding 90 days after surgery.Results: Overall, of 8,435 patients included, 359 (4.3%) were found to have prolonged postoperative opioid prescriptions. The elastic-net penalized logistic regression achieved the best performance in the independent testing set not used for algorithm development with c-statistic=0.70, calibration intercept=0.06, calibration slope=1.02, and Brier score=0.039. The five most important factors for prolonged opioid prescriptions were use of instrumented spinal fusion, preoperative benzodiazepine use, preoperative antidepressant use, preoperative gabapentin use, and uninsured status. Individual patient-level explanations were provided for the algorithm predictions and the algorithms were incorporated into an open access digital application available here: https://sorg-apps.shinyapps.io/lumbaropioidnaive/.Conclusion and Relevance: The clinician decision aid developed in this study may be helpful to preoperatively risk-stratify opioid-naïve patients undergoing lumbar spine surgery. The tool demonstrates moderate discriminative capacity for identifying those at greatest risk of prolonged prescription opioid use. External validation is required to further support the potential utility of this tool in practice. [ABSTRACT FROM AUTHOR]

Background: Incidental durotomy is a common intraoperative complication during spine surgery with potential implications for postoperative recovery, patient-reported outcomes, length of stay, and costs. To our knowledge, there are no processes available for automated surveillance of incidental durotomy.Purpose: The purpose of this study was to develop natural language processing (NLP) algorithms for automated detection of incidental durotomies in free-text operative notes of patients undergoing lumbar spine surgery.Patient Sample: Adult patients 18 years or older undergoing lumbar spine surgery between January 1, 2000 and June 31, 2018 at two academic and three community medical centers.Outcome Measures: The primary outcome was defined as intraoperative durotomy recorded in free-text operative notes.Methods: An 80:20 stratified split was undertaken to create training and testing populations. An extreme gradient-boosting NLP algorithm was developed to detect incidental durotomy. Discrimination was assessed via area under receiver-operating curve (AUC-ROC), precision-recall curve, and Brier score. Performance of this algorithm was compared with current procedural terminology (CPT) and international classification of diseases (ICD) codes for durotomy.Results: Overall, 1,000 patients were included in the study and 93 (9.3%) had a recorded incidental durotomy in the free-text operative report. In the independent testing set (n=200) not used for model development, the NLP algorithm achieved AUC-ROC of 0.99 for detection of durotomy. In comparison, the CPT/ICD codes had AUC-ROC of 0.64. In the testing set, the NLP algorithm detected 16 of 18 patients with incidental durotomy (sensitivity 0.89) whereas the CPT and ICD codes detected 5 of 18 (sensitivity 0.28). At a threshold of 0.05, the NLP algorithm had specificity of 0.99, positive predictive value of 0.89, and negative predictive value of 0.99.Conclusions: Internal validation of the NLP algorithm developed in this study indicates promising results for future NLP applications in spine surgery. Pending external validation, the NLP algorithm developed in this study may be used by entities including national spine registries or hospital quality and safety departments to automate tracking of incidental durotomies. [ABSTRACT FROM AUTHOR]

There is a growing focus on reigning in costs while simultaneously optimizing patient outcomes via a value-based health care (VBHC) transformation. To date, the true cost of care has not been well delineated and many proxies for cost (eg, negotiated reimbursement rates) have been used but are inaccurate and not comprehensive. More robust cost analysis can be done using time-driven activity-based costing (TDABC), a well-documented approach out of Harvard Business School to accurately measure costs. 1) To determine the variation of total cost in 1- or 2- level lumbosacral decompression and fusion surgery and the breakdown of total cost by pre-, intra-, and postoperative care; 2) To determine differences in characteristics between high-cost (top decile) and non-high cost lumbosacral decompression surgeries; 3) To determine the primary cost drivers of 1- or 2-level lumbosacral decompression surgery. Multicenter (one quaternary referral academic medical center and one community hospital) economic analysis. A total of 405 patients who underwent primary 1- or 2-level lumbosacral decompression surgery between November 2, 2021 and December 2, 2022. Variation in total cost, differences between high- and non-high cost patients, and main drivers of total cost (broken down into pre-, intra-, and postoperative cost), as calculated using TDABC. Patients undergoing primary 1- or 2-level lumbosacral decompression and fusion surgery were identified from our institutional database. TDABC methodology was used to calculate total cost. The episode of care was defined as three phases: pre-, intra-, and postoperative. Patient and surgery-related characteristics were identified. To abide by institutional requirements, total cost was normalized to a mean of 1. The variation of total cost was assessed by looking at the most and least expensive total cost. Consistent with prior literature, high cost patients were defined as being in the top decile and a comparison of all factors were made between them and non-high cost patients. Multivariable linear regression was used to identify factors associated with total cost. The highest total cost for a 1- or 2-level lumbosacral decompression and fusion surgery was 9.5x the lowest total cost. On average, intraoperative cost accounted for 87% of the total cost of care. Overall, the hardware itself accounted for 30% of the total cost of care; however, this ranged from 6% to 44% of the total cost of care. High cost patients more often had commercial insurance (n=25 [63%] versus n=190 [52%], p=0.007). When accounting for all other factors, length of stay was associated with increased cost (Regression Coefficient [RC]: 0.02 (95% CI: 0.003 to 0.04), p=0.02). Outpatient surgery (RC: -0.10 (95% CI: -0.18 to -0.01), p=0.027) and multiple surgeons (Surgeons 2, 3, 5, 6, 7, 9, 11, 13, 14, and 15; all p<0.05) were associated with decreased total cost. A wide variation (9.5x difference) in total cost for primary 1- or 2-level lumbosacral decompression and fusion exists. In addition, this study confirms that just under 90% of the total cost is driven by the intraoperative cost, with the large majority being the hardware and technology. Thus, for the same indications, this wide variation in total cost appears to be driven by surgeon preference and idiosyncrasy. Spine surgeons should appreciate these findings and help lead discussions around initiatives and innovations to reduce cost, while also optimizing patient outcomes as part of the VBHC transformation This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Preoperative MRSA screening and decolonization has demonstrated success for some orthopaedic subspecialties in prevention of surgical site infections (SSIs). Spine surgery, however, has seen varied results, potentially secondary to the anatomic and surgical heterogeneity of the patients included in prior studies. Given that prior research has demonstrated greater propensity for gram positive SSIs in the cervical spine, we sought to investigate if MRSA screening would be more impactful in the cervical spine. The purpose of this study was to determine the relationship between nasal MRSA testing and SSI rates specifically in the setting of primary posterior cervical instrumented spine surgery. Retrospective cohort study. Adult patients undergoing primary instrumented posterior cervical procedures from January 2015-December 2019 at two tertiary academic referral centers in an urban setting Physiologic measures: subfascial presumed infected collection or abscess within 90 days of the index operation. Adult patients undergoing primary instrumented posterior cervical procedures from January 2015-December 2019 were reviewed for MRSA testing < 90-days before surgery, preoperative mupirocin, perioperative antibiotics and SSI defined as operative incision and drainage (I&D) < 90-days after surgery. Trauma, tumor and infection cases were excluded. Logistic regression modeling was used with SSI the primary outcome and MRSA screening the primary predictor with clinical and demographic factors as covariates. This study included 668 patients, of whom MRSA testing was performed in 212 patients (31.7%) and 6 (2.8%) were colonized with MRSA. Twelve patients (1.8%) underwent an I&D. On adjusted analysis, preoperative MRSA testing was not associated with postoperative I&D risk. Perioperative vancomycin similarly had no association with postoperative I&D risk. Notably, six patients (50%) grew MSSA from intraoperative cultures, with no cases of MRSA. There was no association between preoperative nasal MRSA screening and SSIs in primary posterior cervical instrumented procedures, nor was there any association between vancomycin or infection rate. Furthermore, there was a preponderance of gram-positive infections but none caused by MRSA. Given these findings, the considerable cost and effort associated with MRSA testing in the setting of primary posterior cervical instrumentation may not be justified. Further research should investigate if higher-risk scenarios demonstrate greater utility of preoperative testing. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Historically, spine surgeons used expected postoperative survival of three months to help select candidates for operative intervention in spinal metastasis. However, this cutoff has been challenged by the development of minimally invasive techniques, novel biologics and advanced radiotherapy. Recent studies have suggested that life expectancy of six weeks may be enough to achieve significant improvements in postoperative health-related quality of life. The purpose of this study was to develop a model capable of predicting six-week mortality in patients with spinal metastases treated with radiation or surgery. Retrospective review was conducted at five large tertiary centers in the United States and Taiwan. The development cohort consisted of 3,001 patients undergoing radiotherapy and/or surgery for spinal metastases from one institution. The validation institutional cohort consisted of 1,303 patients from four independent, external institutions. The primary outcome was six-week mortality. Five models were considered to predict six-week mortality, and the model with the best performance across discrimination, calibration, decision-curve analysis and overall performance was integrated into an open access web-based application. The most important variables for prediction of six-week mortality were albumin, primary tumor histology, absolute lymphocyte, three or more spine metastasis, and ECOG score. The elastic-net penalized logistic model was chosen as the best performing model with AUC 0.84 on evaluation in the independent testing set. On external validation in the 1,303 patients from the four independent institutions, the model retained good discriminative ability with an area under the curve of 0.81. As spinal metastasis patients with shorter life expectancy are considered for operative intervention, the algorithm developed and externally validated in this study may be helpful for preoperative planning, multidisciplinary management, and shared decision-making. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Spinal injuries are relatively common injuries that have a lasting impact on patients and are a significant cause of disability. Gunshot induced spinal injuries (GSIs) are the third most common cause of spinal injury and are increasing in proportion. Despite the severity and frequency of these injuries, there remains a lack of conclusive evidence regarding the optimal management of patients with GSIs. We aimed to better understand the impact of surgical intervention in patients who sustained gunshot induced spinal injuries. Retrospective comparative study. Patients in the National Spinal Cord Injury Statistical Center (NSCISC) database with GSIs and complete one-year follow-up information. (n = 961) The primary outcome measure was defined as improvement in ASIA Impairment Scale from the time of presentation. Patient demographics, clinical information, and outcome data were extracted from the NSCISC database. Surgical intervention was defined as any procedure involving a laminectomy, neural canal restoration, open reduction, spinal fusion, or internal fixation of the spine. Functional assessments included the American Spinal Injury Association (ASIA) Impairment scale. Bivariate analysis as well as multivariate analysis was performed. A total of 961 patients with GSI and one-year follow-up were identified from 1975-2016. The majority of patients were Black/African American (55.6%), male (89.7%), and aged 15-29 (73.8%). Of those who underwent surgical intervention, 34.2% had an improvement in their ASIA Impairment Scale at one year as compared to 20.6% of those treated non-operatively. Overall, surgery was associated with 2.0 [95% CI 1.4 - 2.8] times greater likelihood of ASIA Impairment Scale improvement at one year. Specifically, benefit was seen in thoracic (OR 2.5 [95% CI 1.4-4.6]) and lumbar injuries (OR 1.7 [95% CI 1.1-3.1]), but not cervical injuries. At 5-year follow-up, surgery was associated with 6.2 [95% CI 1.4-16.0] times greater likelihood of improvement in the ASIA Impairment Scale. While the decision to undergo surgery should be individualized, in our large review of GSIs, surgical intervention was associated with a greater likelihood of neurologic recovery. Specifically, patients with thoracic and lumbar GSI have a 2.5- and 1.7-times, respectively, greater likelihood of improvement in their ASIA Impairment Scale one year after injury if they underwent surgical intervention. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Surgical site infections (SSI) constitute significant morbidity in spine surgery. Efforts at SSI prevention include preoperative methicillin-resistant Staphylococcus aureus (MRSA) screening and decolonization, with demonstrated success for arthroplasty patients along with vascular and cardiothoracic surgical patients. The variety of surgical approaches and anatomic regions within spine surgery can limit the impact of analyses at the subspecialty level. Despite the success of MRSA nasal screening and decolonization in reducing SSI rates in other disciplines, the impact on spine surgery is less understood. To determine the relationship between nasal MRSA testing and operative debridement rates for surgical site infection after primary lumbar fusion. Retrospective cohort study at two academic tertiary referral centers. Adult patients (>18 years) were identified from January 2015 to March 2020 based on CPT codes for spinal instrumentation and fusion. Inclusion criteria were primary instrumented posterior lumbar fusion between 1-3 levels and exclusion criteria were revision surgery, tumor, infection, lateral-only surgery or operative surgeon with fewer than 20 cases. Operative incision and drainage (I&D) of the index lumbar spine wound within 90-days after surgery was the primary outcome. Chart text, operative reports and laboratory reports were reviewed for data abstraction. Multivariable logistic regression modeling assessed for demographic differences between MRSA testing groups as well as factors contributing to I&D risk. There were 2,148 patients included with a mean age 62.5 (SD 12.9), 56.9% female, and mean BMI 29.4 (SD 6.2). MRSA testing 90 days prior to surgery was completed in 884 (41.1%) of patients, and 19 (2.2%) of tested patients were colonized with MRSA preoperatively. Thirty-six (1.7%) patients underwent surgical I&D within 90 days of their index procedure for a surgical site infection. I&D risk was not associated with presence or result of MRSA testing, preoperative mupirocin prescriptions, or type of intraoperative antibiotic after controlling for surgeon. I&D risk was associated with higher BMI (5.7% increased risk for every 1 unit increase in BMI or a coefficient of 0.057, 95% confidence interval 0.017 to 0.097, p = 0.005) after controlling for age, diabetes and smoking status. The present study demonstrates no difference in surgical I&D rates between patients who underwent MRSA testing, who had positive MRSA colonization or who underwent other interventions aimed at decreasing SSI rates such as preoperative mupirocin decolonization or addition of intraoperative vancomycin. Increased BMI was associated with risk of undergoing an operative I&D for surgical site infection, suggesting that patient factors dominate over clinical interventions in the prevention of surgical site infection after primary lumbar spine fusion. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]