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Study design Longitudinal cohort. Objective The aims of this study were to measure concordance between patients' and surgeons' preoperative expectations of lumbar surgery, and determine which member of the dyad more closely predicted fulfillment of expectations, defined as patient-reported status postoperatively. Summary of background data Concordant patient-surgeon expectations reflect effective communication and should foster better outcomes. Methods Preoperatively patients and surgeons completed identical surveys measuring expectations for improvement in symptoms and physical/psychosocial function. Responses ranged from "complete improvement" to "do not have this expectation"; scores for each survey ranged from 0 to 100 (greatest expectations). Concordance between pairs of patient-surgeon scores was measured with the intraclass correlation coefficient (ICC). Postoperatively, fulfillment of expectations was measured from patient-reported amount of improvement received and was calculated as the proportion of patient-reported postoperative score relative to patient-reported preoperative score, and surgeon-reported preoperative score (range 0 [no expectations fulfilled] to >1.2 [expectations surpassed]). Clinical measures included patient-reported spine-related disability. Results For 402 patient-surgeon pairs, mean survey scores were 73 ± 19 (patients) and 57 ± 16 (surgeons); 84% of patients had higher scores than surgeons, mainly due to expecting complete improvement, whereas surgeons expected a lot/moderate/little improvement. The ICC for the entire sample was .31 (fair agreement); for subgroups, the greatest difference in ICC was for patients with more spine-related disability (ICC = .10, 95% confidence interval [CI]:0.00-0.23) versus less disability (ICC = .46, 95% CI: 0.34-0.56). 96% of patients were contacted ≥2.0 years postoperatively. Proportions of expectations fulfilled were 0.79 (0-3.00) (patients) and 1.01 (0-2.29) (surgeons). Thus patients were less likely to anticipate subsequent postoperative status (odds ratio [OR] 0.34, 95% CI 0.25-0.45) versus surgeons who were more likely to anticipate patient-reported postoperative status (OR 2.98, 95% CI: 2.22-4.00). Conclusion Concordance between patients' and surgeons' expectations was fair; due mostly to patients expecting complete improvement whereas surgeons expected a lot/moderate/little improvement. Compared to patients' expectations, surgeons' expectations more closely coincided with patient-reported fulfillment of expectations 2 years postoperatively.Level of Evidence: 1.

STUDY DESIGN Retrospective review of prospectively collected database. OBJECTIVE To delineate and visualize trajectories of the functional status in surgically-treated adult spinal deformity (ASD) patients. SUMMARY OF BACKGROUND DATA Classifying long-term recovery following ASD surgery is not well defined. METHODS One thousand one hundred seventy-one surgically-treated patients with a minimum of 3-year follow-up were included. The group-based trajectory modeling (GBTM) was used to identify distinct trajectories of functional status over time, measured by Oswestry Disability Index (ODI). Patient profiles were then compared according to the observed functional patterns. RESULTS The GBTM identified four distinct functional patterns. The first group (10.0%) started with minimal disability (ODI: 15 ± 10) and ended up almost disability-free (low-low). The fourth group (21.5%) began with high ODI (66 ± 11) and improvement was minimal (high-high). Groups two (40.1%) and three (28.4%) had moderate disability (ODI: 39 ± 11 vs. 49 ± 11, P

Study design Systematic review. Objective To determine the difference in postoperative sagittal alignment when single level cervical radiculopathy or myelopathy is treated with an anterior cervical discectomy and fusion (ACDF) using a structural graft and plate, a stand-alone ACDF, or a total disc arthroplasty (TDR). We also wanted to determine if postoperative sagittal alignment impacted clinical outcomes in this patient population. Summary of background data Although there are several accepted techniques for interbody reconstruction during single level anterior cervical surgery, little is known on the impact of any of them on segmental and regional sagittal alignment. Methods A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines of the PubMed, Embase, and Cochrane databases. Only studies which contained pre and postoperative C2-7 Cobb angles as well as Neck Disability Index (NDI) scores following single level traditional ACDF with plate and cage, stand-alone ACDF, or TDR with at least 1 year follow up were included. Results There were 12 publications that fulfilled the inclusion criteria with a total of 658 patients. Cluster regression analysis showed no difference between treatment arms at each respective time-point or in the overall change in NDI from preoperative to postoperative (P = 0.88). Cluster regression analysis showed no difference between treatment arms at each respective time point or in the overall change in lordosis from pre-op to post-op (P = 0.93). Conclusion This review provides evidence that while NDI scores improved across all devices, there was no significant difference in NDI improvement or C2-7 Cobb angle change between single level traditional ACDF, stand-alone ACDF, or TDR. Although TDR has not been considered a lordosis producing operation, our investigation shows it does not differ significantly in sagittal profile from other cervical fusion techniques. Moreover, we show that the NDI score improved, regardless of device implanted. Level of evidence 1.

STUDY DESIGN Retrospective database analysis. OBJECTIVE To identify preoperative risk factors for emergency department (ED) visit and unplanned hospital readmission after primary anterior cervical discectomy and fusion (ACDF) at 30 and 90 days. SUMMARY OF BACKGROUND DATA Limited data exist to identify factors associated with ED visit or readmission after primary ACDF within the first 3 months following surgery. METHODS Patients undergoing ACDF from 2005 to 2012 were identified in the Statewide Planning and Research Cooperative System database. Multivariable regression models were created based on patient-level and surgical characteristics to identify independent risk factors for hospital revisit. RESULTS Of 41,813 patients identified, 2514 (6.0%) returned to the ED within 30 days of discharge. Risk factors included age 1, length of stay (LOS) greater than 1 day (OR 1.23), and fusion of > 2 levels (OR 1.17). Four thousand six hundred nine (11.0%) patients returned to the ED within 90 days. Risk factors mirrored those at 30 days. Patients having private insurance or those discharged to rehab were less likely to present to the ED. One thousand three hundred ninety-four (3.3%) patients were readmitted by 30 days. Risk factors included male sex, Medicare, or Medicaid insurance (OR 1.71 and 1.79 respectively), Charlson comorbidity index > 1, discharge to a skilled nursing facility (OR 2.90), infectious/pathologic (OR 3.296), or traumatic (OR 1.409) surgical indication, LOS > 1 day (OR 1.66), or in-hospital complication. 2223 (5.3%) patients were readmitted by 90 days. Risk factors mirrored those at 30 days. No differences in readmission were seen based on race or number of levels fused. Patients aged 18 to 34 were less likely to be readmitted versus patients older than 35. CONCLUSION Insurance status, comorbidities, and LOS consistently predicted an unplanned hospital visit at 30 and 90 days. Although nondegenerative surgical indications and in-hospital complications did not predict ED visits, these factors increased the risk for readmission. LEVEL OF EVIDENCE 3.

Study design Prospective cohort study. Objective To examine preoperative urinary cross-linked n-telopeptide (uNTx) and assess for association with fusion rates in patients undergoing single and multi-level anterior cervical decompression and fusion (ACDF). Summary of background data Although high rates of fusion have been reported for ACDF, the risk of pseudarthrosis remains substantial. An established marker of bone turnover, uNTx may prove useful as a predictor of fusion. Methods Patients undergoing primary ACDF with allograft/plating technique from 2015 to 2017 by a single surgeon were consecutively enrolled and preoperative uNTx was collected. Patients undergoing revision, with creatinine >1.2, and with improperly-collected uNTx were excluded. Demographics, laboratory values, and fusion status were assessed at 6 months, 1 year, and 2 years postoperatively. Results Of the 97 patients enrolled, 69 met inclusion criteria. Of included cases, 41%, 33%, 18%, and 8% underwent 1-, 2-, 3-, and 4-level ACDF, respectively. Overall, fusion rates were 37.3%, 70.9%, and 95.3% at 6 months, 1 year, and 2 years, respectively. uNTx was higher in the fusion group (31.1 vs. 22.2, P = 0.001) at 6 months and 1 year (30.0 vs. 21.0, P = 0.006), with no difference at 2 years. No differences were identified in the proportion of smokers, immunomodulatory agents, corpectomies, or fusion levels between groups. Multivariate regression analysis demonstrated that uNTx is an independent predictor of fusion (odds ratio, OR, 1.124, P = 0.003). Both groups experienced improvements in NDI and VAS neck pain at 6 months with no significant differences noted between groups. Of 16 patients with pseudarthrosis at 1 year, 2 underwent posterior cervical fusion for symptoms. Conclusion Preoperative uNTx was greater in patients with successful ACDF fusion compared with patients with pseudarthrosis at 6 months and 1 year. A negative correlation was found between preoperative uNTx and motion on dynamic imaging. These results suggest that uNTx could serve to identify patients at risk for pseudarthrosis after ACDF. Level of evidence 3.

Retrospective review of prospective multicenter database.To identify an optimal set of factors predicting the risk of proximal junctional failure (PJF) while taking the time dependency of PJF and those factors into account.Surgical correction of adult spinal deformity (ASD) can be complex and therefore, may come with high revision rates due to PJF.Seven hundred sixty-three operative ASD patients with a minimum of 1-year follow-up were included. PJF was defined as any type of proximal junctional kyphosis (PJK) requiring revision surgery. Time-dependent ROC curves were estimated with corresponding Cox proportional hazard models. The predictive abilities of demographic, surgical, radiographic parameters, and their possible combinations were assessed sequentially. The area under the curve (AUC) was used to evaluate models' performance.PJF occurred in 42 patients (6%), with a median time to revision of approximately 1 year. Larger preoperative pelvic tilt (PT) (hazard ratio [HR]=1.044, P = 0.034) significantly increased the risk of PJF. With respect to changes in the radiographic parameters at 6-week postsurgery, larger differences in pelvic incidence-lumbar lordosis (PI-LL) mismatch (HR = 0.924, P = 0.002) decreased risk of PJF. The combination of demographic, surgical, and radiographic parameters has the best predictive ability for the occurrence of PJF (AUC = 0.863), followed by demographic along with radiographic parameters (AUC = 0.859). Both models' predictive ability was preserved over time.Over correction increased the risk of PJF. Radiographic along with demographic parameters have shown the approximately equivalent predictive ability for PJF over time as with the addition of surgical parameters. Radiographic rather than surgical factors may be of particular importance in predicting the development of PJF over time. These results set the groundwork for risk stratification and corresponding prophylactic interventions for patients undergoing ASD surgery.4.

Retrospective review of prospective multicenter database.To investigate the determinants of patient satisfaction with respect to changes in functional limitations 2 years after spinal deformity surgery.For operatively treated adult spine deformity (ASD), patient satisfaction has become an important component of evaluating quality of care.A total of 430 operative patients with ASD with 2-year follow-up were analyzed. Patient satisfaction was assessed using the Scoliosis Research Society 22-item. Latent class analysis was performed to assign individuals to classes based on the changes in pre- and 2-year postoperative functions, assessed using the Oswestry Disability Index (ODI). An ordered logistic regression was conducted to assess the association of class membership and satisfaction.Latent class analysis identified four classes. The worsened-condition class (WC: 1.4%) consisted of patients who were likely to experience worsened function, particularly in lifting and pain intensity. The remained-same class (RS: 13.0%) included patients who remained the same, because the majority reported approximately no change in walking, standing, and sitting. The mild-improved class (mild-I: 40.2%) included patients with mildly enhanced conditions, specifically, in standing, social life, and employment. The most-improved class (most-I: 45.3%) included patients with great improvement after surgery mainly in standing, followed by social life and employment. The odds of being satisfied were significantly increased by 3.91- (P 0.001) and 16.99-fold (P 0.001), comparing patients in mild-I and most-I to the RS/WC class, respectively, after controlling for confounders.Improvement in standing, social life, and employment are the most important determinants of patient satisfaction postsurgery. Reduced pain intensity and enhanced walking ability also help to elevate patient satisfaction. However, lifting, personal care, sitting, sleeping, and travelling may be of less importance. Examining the heterogeneity of patient-reported outcome in patients with ASD allows the identification of classes with different patient characteristics and satisfaction, and thus, help to guide tailored provision of care.4.

Longitudinal cohort.The aims of this study were to measure concordance between patients' and surgeons' preoperative expectations of lumbar surgery, and determine which member of the dyad more closely predicted fulfillment of expectations, defined as patient-reported status postoperatively.Concordant patient-surgeon expectations reflect effective communication and should foster better outcomes.Preoperatively patients and surgeons completed identical surveys measuring expectations for improvement in symptoms and physical/psychosocial function. Responses ranged from "complete improvement" to "do not have this expectation"; scores for each survey ranged from 0 to 100 (greatest expectations). Concordance between pairs of patient-surgeon scores was measured with the intraclass correlation coefficient (ICC). Postoperatively, fulfillment of expectations was measured from patient-reported amount of improvement received and was calculated as the proportion of patient-reported postoperative score relative to patient-reported preoperative score, and surgeon-reported preoperative score (range 0 [no expectations fulfilled] to1.2 [expectations surpassed]). Clinical measures included patient-reported spine-related disability.For 402 patient-surgeon pairs, mean survey scores were 73 ± 19 (patients) and 57 ± 16 (surgeons); 84% of patients had higher scores than surgeons, mainly due to expecting complete improvement, whereas surgeons expected a lot/moderate/little improvement. The ICC for the entire sample was .31 (fair agreement); for subgroups, the greatest difference in ICC was for patients with more spine-related disability (ICC = .10, 95% confidence interval [CI]:0.00-0.23) versus less disability (ICC = .46, 95% CI: 0.34-0.56). 96% of patients were contacted ≥2.0 years postoperatively. Proportions of expectations fulfilled were 0.79 (0-3.00) (patients) and 1.01 (0-2.29) (surgeons). Thus patients were less likely to anticipate subsequent postoperative status (odds ratio [OR] 0.34, 95% CI 0.25-0.45) versus surgeons who were more likely to anticipate patient-reported postoperative status (OR 2.98, 95% CI: 2.22-4.00).Concordance between patients' and surgeons' expectations was fair; due mostly to patients expecting complete improvement whereas surgeons expected a lot/moderate/little improvement. Compared to patients' expectations, surgeons' expectations more closely coincided with patient-reported fulfillment of expectations 2 years postoperatively.Level of Evidence: 1.

Retrospective review of prospectively collected database.To delineate and visualize trajectories of the functional status in surgically-treated adult spinal deformity (ASD) patients.Classifying long-term recovery following ASD surgery is not well defined.One thousand one hundred seventy-one surgically-treated patients with a minimum of 3-year follow-up were included. The group-based trajectory modeling (GBTM) was used to identify distinct trajectories of functional status over time, measured by Oswestry Disability Index (ODI). Patient profiles were then compared according to the observed functional patterns.The GBTM identified four distinct functional patterns. The first group (10.0%) started with minimal disability (ODI: 15 ± 10) and ended up almost disability-free (low-low). The fourth group (21.5%) began with high ODI (66 ± 11) and improvement was minimal (high-high). Groups two (40.1%) and three (28.4%) had moderate disability (ODI: 39 ± 11 vs. 49 ± 11, P 0.001) before surgery. Following surgery, marked improvement was seen in group two (median-low), but deterioration/no change was observed in group three (median-high). The low-low group primarily included adult idiopathic scoliosis, while the high-high group had the oldest and the most severe patients as compared with the rest of the groups. A subgroup analysis was performed between groups two and three with propensity score matching on age, body mass index, baseline physical component score (PCS), and severity of deformity. Notably, the baseline mental status of the median-high group was significantly worse than that of the median-low group, though the differences in demographics, surgery, and deformity no longer existed.Patients with moderate-to-low disability are more likely to obtain better functional postoperative outcomes. Earlier surgical interventions should be considered to prevent progression of deformity, and to optimize favorable outcomes. Greatest improvement appears to occur in moderately disabled patients with good mental health. GBTM permits classification into distinct groups, which can help in surgical decision making and setting expectations regarding recovery.3.

STUDY DESIGN Prospective Cohort Study OBJECTIVE.: The aim of this study was to validate the Patient Reported Outcomes Measurement Information System (PROMIS) against existing patient-reported outcomes in the cervical spine. SUMMARY OF BACKGROUND DATA Current patient-reported outcomes in cervical spine have substantial limitations. PROMIS offers the potential for improved psychometric properties with reduced questionnaire burden. METHODS Adult patients undergoing cervical spine surgery at a single institution between 2016 and 2018 were prospectively enrolled. Patients completed questionnaires (36-Item Short Form Health Survey [SF-36], Neck Disability Index (NDI), Visual Analog Scale arm/neck, and PROMIS pain Interference [PI], physical Function [PF], and Upper Extremity [UE]) preoperatively and at 6 months postoperatively. Demographic data, diagnosis, and procedural data were recorded. Validation of the instruments was completed with a Rasch Model as well as measurement of coverage, efficiency, test-retest reliability, responsiveness, and convergent validity. RESULTS Of 197 patients who completed the preoperative survey, 164 were eligible for 6-month follow-up and 139 completed 6-month postoperative surveys. The most common diagnoses were radiculopathy (37.6%), myeloradiculopathy (30.5%), and myelopathy (28.4%). All studied instruments had acceptable fit to a Rasch model. PROMIS computer adaptive testings (CATs) demonstrated improved average time to completion for PI (39 seconds), PF (47 seconds), and UE (54 seconds), compared to NDI (117 s) and SF-36 PCS (175 seconds). Responsiveness for PROMIS CATs was similar to NDI and SF-36, test-retest reliability was lower for PI (intraclass correlation: 0.68), PF (0.70), and UE (0.59), compared to NDI (0.86) and PCS (0.85). For convergent validity, PI was strongly correlated to NDI and PF to SF-36 PCS. There were no significant floor or ceiling effects for the PROMIS domains, although UE had preoperative clustering (n = 18) at a high score (56.4) and PI had postoperative clustering (n = 27) at a low score (38.7). CONCLUSION PROMIS CATs demonstrate several advantages, including efficiency and responsiveness, while demonstrating good convergent validity with legacy instruments. Nevertheless, CATs had lower test-retest reliability and had significant clustering at higher levels of function for the PI and UE CATs. These limitations must be considered before broad adoption of CATs in cervical spine patients. LEVEL OF EVIDENCE 3.

STUDY DESIGN Single-center retrospective study. OBJECTIVE Investigate how differing degrees of pelvic incidence (PI) modulate the recruitment of pelvic tilt (PT) in response to similar amounts of sagittal malalignment as measured by T1-Pelvic Angle (TPA). SUMMARY OF BACKGROUND DATA Past research has shown that some patients do not recruit PT in response to sagittal malalignment. Given the anatomic relationship between PI and PT, we sought to determine whether differing PI is associated with variable recruitment of PT. METHODS Single-center retrospective study of 2077 patients undergoing full body radiographs and TPA>10°. Five groups of patients (Very Low, Low, Average, High, and Very High PI) were defined utilizing PI ranges on a Gaussian distribution. Linear regression (LR) evaluated correlation of TPA to PT within each PI group. Multivariate LR evaluated whether correlation between TPA and PT differed between each PI group. RESULTS Mean PT increased with increasing levels of PI (P

Systematic review.To determine the difference in postoperative sagittal alignment when single level cervical radiculopathy or myelopathy is treated with an anterior cervical discectomy and fusion (ACDF) using a structural graft and plate, a stand-alone ACDF, or a total disc arthroplasty (TDR). We also wanted to determine if postoperative sagittal alignment impacted clinical outcomes in this patient population.Although there are several accepted techniques for interbody reconstruction during single level anterior cervical surgery, little is known on the impact of any of them on segmental and regional sagittal alignment.A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines of the PubMed, Embase, and Cochrane databases. Only studies which contained pre and postoperative C2-7 Cobb angles as well as Neck Disability Index (NDI) scores following single level traditional ACDF with plate and cage, stand-alone ACDF, or TDR with at least 1 year follow up were included.There were 12 publications that fulfilled the inclusion criteria with a total of 658 patients. Cluster regression analysis showed no difference between treatment arms at each respective time-point or in the overall change in NDI from preoperative to postoperative (P = 0.88). Cluster regression analysis showed no difference between treatment arms at each respective time point or in the overall change in lordosis from pre-op to post-op (P = 0.93).This review provides evidence that while NDI scores improved across all devices, there was no significant difference in NDI improvement or C2-7 Cobb angle change between single level traditional ACDF, stand-alone ACDF, or TDR. Although TDR has not been considered a lordosis producing operation, our investigation shows it does not differ significantly in sagittal profile from other cervical fusion techniques. Moreover, we show that the NDI score improved, regardless of device implanted.1.

Study design Retrospective case-control study. Objective To report culturing patterns and results in the setting of presumed aseptic revision spinal surgery. Summary of background data The indications for obtaining cultures in revision spinal surgery remain unclear in the absence of a definitive diagnosis of infection. Culture results and risk factors for having positive cultures in this setting have not been previously studied. Methods We retrospectively reviewed 595 consecutive revision spine surgeries performed by four senior spine surgeons between 2008 and 2013. Preoperative workup revealed the diagnosis of infection in 17 cases which were excluded from review. The remaining 578 presumed aseptic cases were included. Univariate and multivariate analyses were performed to identify variables associated with obtaining cultures and risk factors for positive cultures. Results Cultures were obtained in 112 (19.4%) cases and were positive in 40.2%. Pseudarthrosis was the most common revision diagnosis when cultures were obtained (49.1%) and Propionibacterium acnes was the most common organism isolated from positive cultures (48.8%). Regarding culture results, multivariate analysis demonstrated that male sex (odds ratio [OR] = 3.4) and pseudarthrosis (OR = 4.1) were significantly associated with having positive cultures while fusion procedures (OR = 0.3) were negatively correlated, with area under the curve (AUC) 0.71. Conclusion Unexpected positive cultures occurred commonly and P. acnes was the predominant isolated organism. Male sex, pseudarthrosis, and non-fusion cases predicted positive cultures. Considering these results, we recommend cultures be obtained in revision cases for pseudarthrosis, even in the setting of negative infectious work-up preoperatively. Level of evidence 4.