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Preoperative embolization (PE) reduces intraoperative blood loss during surgery for spinal metastases of hypervascular primary tumors such as thyroid and renal cell tumors. However, most spinal metastases originate from primary breast, prostate, and lung tumors and it remains unclear whether these and other spinal metastases benefit from PE.To assess the (1) efficacy of PE on the amount of intraoperative blood loss and safety in patients with spinal metastases originating from non-hypervascular primary tumors, and (2) secondary outcomes including perioperative allogeneic blood transfusion, anesthesia time, hospitalization, postoperative complication within 30 days, reoperation, 90-day mortality, and 1-year mortality.Retrospective propensity-score matched, case-control study at 2 academic tertiary medical centers.Patients 18 years of age or older undergoing surgery for spinal metastases originating from primary non-thyroid, non-renal cell, and non-hepatocellular tumors between January 1, 2002 and December 31, 2016 were included.The primary outcomes were estimated amount of intraoperative blood loss and complications attributable to PE, such as neurologic injury, wound infection, thrombosis, or dissection. The secondary outcomes included perioperative allogeneic blood transfusion, anesthesia time, hospitalization, postoperative complication within 30 days, reoperation, 90-day mortality, and 1-year mortality.In total, 495 patients were identified, of which 54 (11%) underwent PE. After propensity score matching on 21 variables, including primary tumor, number of spinal levels, and surgical treatment, 53 non-PE patients were matched to 53 PE patients. Matching was adequate measured by comparing the matched variables, testing the standardized mean differences (0.25), and inspecting Kernel density plots. The degree of embolization was noted to be complete, until stasis, or successful in 43 (80%) patients.Intraoperative blood loss did not differ between both groups with a median blood loss in liters of 0.6 (IQR, 0.4-1.2) for non-PE patients and 0.9 (IQR, 0.6-1.2) for PE patients (p=.32). No complications occurred during embolization or the time between embolization and surgery. No differences were found in terms of the secondary outcomes.Our data suggest that, although no complications occurred and the embolization procedure can be considered safe, patients with non-hypervascular spinal metastases might not benefit from PE. A larger, prospective study could confirm or refute these study findings and aid in elucidating a subset of spinal metastases that might benefit from PE.

BACKGROUND CONTEXT The increasing volume of free-text notes available in electronic health records has created an opportunity for natural language processing (NLP) algorithms to mine this unstructured data in order to detect and predict adverse outcomes. Given the volume and diversity of documentation available in spine surgery, it remains unclear which types of documentation offer the greatest value for prediction of adverse outcomes. STUDY DESIGN/SETTING Retrospective review of medical records at two academic and three community hospitals. PURPOSE The purpose of this study was to conduct an exploratory analysis in order to examine the utility of free-text notes generated during the index hospitalization for lumbar spine fusion for prediction of 90-day unplanned readmission. PATIENT SAMPLE Adult patients 18 years or older undergoing lumbar spine fusion for lumbar spondylolisthesis or lumbar spinal stenosis between January 1, 2016 and December 31, 2020. OUTCOME MEASURES The primary outcome was inpatient admission within 90-days of discharge from the index hospitalization. METHODS The predictive performance of NLP algorithms developed by using discharge summary notes, operative notes, nursing notes, physical therapy notes, case management notes, medical doctor (MD) (resident or attending), and allied practice professional (APP) (nurse practitioner or physician assistant) notes were assessed by discrimination, calibration, overall performance. RESULTS Overall, 708 patients were included in the study and 83 (11.7%) had 90-day inpatient readmission. In the independent testing set of patients (n=141) not used for model development, the area under the receiver operating curve of NLP algorithms for prediction of 90-day readmission using discharge summary notes, operative notes, nursing notes, physical therapy notes, case management notes, MD/APP notes was 0.70, 0.57, 0.57, 0.60, 0.60, and 0.49 respectively. CONCLUSION In this exploratory analysis, discharge summary, physical therapy, and case management notes had the most utility and daily MD/APP progress notes had the least utility for prediction of 90-day inpatient readmission in lumbar fusion patients among the free-text documentation generated during the index hospitalization.

BACKGROUND CONTEXT: Although survival of patients with spinal metastases has improved over the last decades due to advances in multi-modal therapy, there are currently no reliable predictors of mortality. Body composition measurements obtained using computed tomography (CT) have been recently proposed as biomarkers for survival in patients with and without cancer. Patients with cancer routinely undergo CT for staging or surveillance of therapy. Body composition assessed using opportunistic CTs might be used to determine survival in patients with spinal metastases. PURPOSE: The purpose of this study was to determine the value of body composition measures obtained on opportunistic abdomen CTs to predict 90-day and 1-year mortality in patients with spinal metastases undergoing surgery. We hypothesized that low muscle and abdominal fat mass were positive predictors of mortality. STUDY DESIGN: Retrospective study at a single tertiary care center in the United States. PATIENT SAMPLE: This retrospective study included 196 patients between 2001 and 2016 that were 18 years of age or older, underwent surgical treatment for spinal metastases, and had a preoperative CT of the abdomen within three months prior to surgery. OUTCOME MEASURES: 90-day and 1-year mortality by any cause. METHODS: Quantification of cross-sectional areas (CSA) and CT attenuation of abdominal subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), and paraspinous and abdominal skeletal muscle were performed on CT images at the level of L4 using an in-house automated algorithm. Sarcopenia was determined by total muscle CSA (cm(2)) divided by height squared (m(2)) with cutoff values of

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.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.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.The primary outcome was incision and drainage performed in the operating room within 90 days of surgery.MRSA testing90-day's before surgery, mupirocin prescription30-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 ID rate.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 ID rates. MRSA testing, mupirocin prescriptions, perioperative parenteral vancomycin use, and intrawound vancomycin powder use had no impact on ID rates. ID 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).The present study demonstrates no impact on surgical ID rates from the use of preoperative MRSA testing. Increased BMI and transfusions were associated with operative ID 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.

BACKGROUND CONTEXT Incidental durotomy during elective spine surgery is relatively common. While usually benign and self-limited, it can be associated with morbidity, increased cost, and medicolegal ramifications. Dural repair typically involves performing a primary closure using a suture or dural staple; repairs are then frequently augmented with a sealant, patch, or fat/fascial graft. Although primary repair of an incidental durotomy is standard practice, the ideal secondary sealant or augment choice remains unclear. A wide variety of commercially available dural sealant options exist, and while none have demonstrated consistent superiority, all are associated with single-use costs in the hundreds to thousands of dollars and have concerns regarding swelling, local inflammation, or short-lived dural adherence. PURPOSE The goal of this study is to compare the results of dural repair augmentation using an open intraoperative epidural blood patch to a hydrogel technique. STUDY DESIGN/SETTING Retrospective comparative cohort study at an academic referral center PATIENT SAMPLE Adult patients undergoing lumbar spine surgery from March 2017 to January 2021 who sustained an incidental durotomy. Patients undergoing surgery for infection were excluded. OUTCOME MEASURES The primary outcome was failure of the repair as determined by a return to the operating room for re-exploration of a persistent cerebrospinal fluid (CSF) leak within 30 days of the index procedure. A secondary outcome was the incidence of a postoperative positional headache, and if present, the method used to obtain resolution. The primary predictor was use of a suture and hydrogel technique (“hydrogel” group), or the use of an epidural blood patch (“EBP” group). METHODS The method for applying an open epidural blood patch is presented in detail and involves primarily repairing the durotomy followed by allowing whole blood to pool and clot in the operative field until the durotomy is completely covered. This was compared with a group of patients undergoing secondary augmentation with commercially available hydrogel. In both groups, mechanical resistance to CSF leakage was confirmed with direct visualization and a Valsalva maneuver, respectively. Patients were instructed to remain flat until the morning after surgery. Chart review was used for data abstraction on preoperative, demographic, perioperative, and postoperative clinical factors. To compare between the hydrogel and EBP group, Wilcoxon rank-sum testing was used to test for non-parametric comparisons of means, and chi-square testing between binomial data. RESULTS Of 732 patients during the study period, forty-eight patients met study criteria. Twenty-five patients were in the hydrogel group and 23 in the EBP group. Mean age was 69.3 years (standard error 1.3 years). Patients were predominantly female (n = 31, 64.6%) with a mean BMI of 29.5 (SE 0.8), with no significant baseline differences between the hydrogel and EBP groups. Two patients in the hydrogel group (8.0%) and two in the EBP group (8.7%) had mild positional headaches postoperatively that resolved without intervention within 24 hours. One (4.3%) patient in the EBP group had positional headaches following an initial headache-free period; this patient was returned to the operating room and no evidence of a persistent CSF leak was found despite meticulous exploration. CONCLUSIONS An open, intraoperatively placed epidural blood patch may be an efficacious and cost-effective way to manage an incidental durotomy. This method merits further study as an allergy-free, no swell, cost-neutral method of dural repair augmentation.

BACKGROUND Anterior lumbar spine surgery (ALSS) requires mobilization of the great vessels, resulting in a high risk of iatrogenic vascular injury (VI). It remains unclear whether VI is associated with increased risk of postoperative complications and other related adverse outcomes. PURPOSE The purpose of this study was to (1) assess the incidence of postoperative complications attributable to VI during ALSS, and (2) outcomes secondary to VI such as procedural blood loss, transfusion of blood products, length of stay (LOS), and in hospital mortality. STUDY DESIGN Retrospective propensity-score matched, case-control study at 2 academic and 3 community medical centers, PATIENT SAMPLE Patients 18 years of age or older, undergoing ALSS between January 1st, 2000 and July 31st, 2019 were included in this analysis. OUTCOME MEASURES The primary outcome was the incidence of postoperative complications attributable to VI, such as venous thromboembolism, compartment syndrome, transfusion reaction, limb ischemia, and reoperations. The secondary outcomes included estimated operative blood loss (milliliter), transfused blood products, LOS (days), and in-hospital mortality. METHODS In total, 1,035 patients were identified, of which 75 (7.2%) had a VI. For comparative analyses, the 75 VI patients were paired with 75 comparable non-VI patients by propensity-score matching. The adequacy of the matching was assessed by testing the standardized mean differences (SMD) between VI and non-VI group (>0.25 SMD). RESULTS Two patients (2.7%) had VI-related postoperative complications in the studied period, which consisted of two deep venous thromboembolisms (DVTs) occurring on day 3 and 7 postoperatively. Both DVTs were located in the distal left common iliac vein (CIV). The VI these patients suffered were to the distal inferior vena cava and the left CIV, respectively. Both patients did not develop additional complications in consequence of their DVTs, however, did require systemic anticoagulation and placement of an inferior vena cava filter. There was no statistical difference with the non-VI group where no instances (0%) of postoperative complications were reported (p=.157). No differences were found in LOS or in hospital mortality between the two groups (p=.157 and p=.999, respectively). Intraoperative blood loss and blood transfusion were both found to be higher in the VI group in comparison to the non-VI group (650 mL, interquartile range [IQR] 300–1400 vs. 150 mL, IQR 50–425, p≤.001; 0 units, IQR 0–3 vs. 0 units, IQR 0–1, p=.012, respectively). CONCLUSION This study found a low number of serious postoperative complications related to VI in ALSS. In addition, these complications were not significantly different between the VI and matched non-VI ALSS cohort. Although not significant, the found DVT incidence of 2.7% after VI in ALSS warrants vigilance and preventive measures during the postoperative course of these patients.

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.

Recent applications of artificial intelligence have shown great promise for improving the quality and efficiency of clinical care. Numerous clinical decision support tools exist in today's electronic health records (EHRs) such as medication dosing support, order facilitators (eg, procedure specific order sets), and point of care alerts. However, less has been done to integrate artificial intelligence (AI)-enabled risk predictors into EHRs despite wide availability of validated risk prediction tools. An interoperability standard known as SMART on FHIR (substitutable medical applications and reusable technologies on fast health interoperability resources) offers a promising path forward, enabling digital innovations to be seamlessly integrated with the EHR with regard to the user interface and patient data. For the next step in progress towards the goal of learning healthcare and informatics-enabled spine surgery, we propose the application of SMART on FHIR to integrate existing and new risk predictions tools in spine surgery through an EHR add-on-application.

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.

BACKGROUND CONTEXT The SORG machine-learning algorithms were previously developed for preoperative prediction of overall survival in spinal metastatic disease. On sub-group analysis of a previous external validation, these algorithms were found to have diminished performance on patients treated after 2010. PURPOSE The purpose of this study was to assess the performance of these algorithms on a large contemporary cohort of consecutive spinal metastatic disease patients. STUDY DESIGN/SETTING Retrospective study performed at a tertiary care referral center. PATIENT SAMPLE Patients of 18 years and older treated with surgery for metastatic spinal disease between 2014 and 2016. OUTCOME MEASURES Ninety-day and one-year mortality. METHODS Baseline patient and tumor characteristics of the validation cohort were compared to the development cohort using bivariate logistic regression. Performance of the SORG algorithms on external validation in the contemporary cohort was assessed with discrimination (c-statistic and receiver operating curve), calibration (calibration plot, intercept, and slope), overall performance (Brier score compared to the null-model Brier score), and decision curve analysis. RESULTS Overall, 200 patients were included with 90-day and 1-year mortality rates of 55 (27.6%) and 124 (62.9%), respectively. The contemporary external validation cohort and the developmental cohort differed significantly on primary tumor histology, presence of visceral metastases, American Spinal Injury Association impairment scale, and preoperative laboratory values. The SORG algorithms for 90-day and 1-year mortality retained good discriminative ability (c-statistic of 0.81 [95% confidence interval [CI], 0.74–0.87] and 0.84 [95% CI, 0.77–0.89]), overall performance, and decision curve analysis. The algorithm for 90-day mortality showed almost perfect calibration reflected in an overall calibration intercept of −0.07 (95% CI: −0.50, 0.35). The 1-year mortality algorithm underestimated mortality mainly for the lowest predicted probabilities with an overall intercept of 0.57 (95% CI: 0.18, 0.96). CONCLUSIONS The SORG algorithms for survival in spinal metastatic disease generalized well to a contemporary cohort of consecutively treated patients from an external institutional. Further validation in international cohorts and large, prospective multi-institutional trials is required to confirm or refute the findings presented here. The open-access algorithms are available here: https://sorg-apps.shinyapps.io/spinemetssurvival/ .

Background Context : Reliable estimation of the likelihood for prolonged postoperative opioid use may aid targeted interventions for high-risk patients. Previous studies have recommended differing methodologies for prediction of sustained postoperative opioid use. Purpose : To compare the performance of the Stopping Opioids after Surgery (SOS) score and preoperative morphine milligram equivalents (MME) for postoperative opioid prescription exposure in a contemporary cohort of lumbar surgery patients. Patient Sample : Adult patients undergoing posterior decompression with or without fusion for degenerative lumbar conditions between January 31st, 2016 and May 31st, 2019. Study Design/Setting : Retrospective review at two academic medical centers and three community hospitals. Outcome Measures : The primary outcome was sustained postoperative prescription opioid exposure at 3-months and 6-months. Reoperations and readmissions were considered secondarily. Methods : SOS score and MME were assigned to patients based on data from their pre-operative surgical evaluation. Performance for both measures was assessed for all outcomes by discrimination, including c-statistic and receiver-operating curve analysis. Calibration of the low, medium and high-risk strata with the observed rates of postoperative adverse events were examined. Results : Overall, 4165 patients were included in this study. Pre-operative prevalence of prescription opioid use was 31%. Rates of postoperative opioid prescriptions at 3-months and 6-months, were 3.3% (n = 136) and 1.5% (n = 61). The c-statistics of preoperative oral MME and SOS score for 3-month sustained opioid prescriptions were 0.64 and 0.78, respectively. The c-statistics of preoperative oral MME and SOS score for 6-month sustained opioid prescriptions were 0.64 and 0.82, respectively. C-statistics of preoperative oral MME and SOS score were much lower for reoperation and readmission, although SOS score outperformed MME for both outcomes. Conclusion : The SOS score clinically outperformed oral MME as a predictive measure for outcomes following lumbar spine surgery. The SOS score may be valuable for identifying individuals at high-risk for sustained prescription opioid use and associated adverse events following spine surgery.

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.

BACKGROUND Osteoporotic vertebral compression fractures (OVCF) account for a substantial portion of the US healthcare financial burden. With a growing elderly population, the number of fractures contributing to sagittal imbalance is expected to increase. For those patients undergoing surgery, preoperative markers, such as albumin, may help to predict the occurrence of postoperative complications. PURPOSE To evaluate the association between preoperative serum albumin levels and the incidence of postoperative complications, mortality, and 30-day readmissions following surgical intervention for OVCF. STUDY DESIGN Retrospective study. PATIENT SAMPLE Patient data were obtained from the American College of Surgeons National Surgery Quality Improvement Project (ACS-NSIP) database between the years 2007 and 2014. OUTCOME MEASURES No outcome measures related to self-reporting, physiology, or functionality were evaluated in this study. Primary outcome measures analyzed included various postoperative complications, patient mortality, and 30-day readmission. METHODS A retrospective analysis of the American College of Surgeons National Surgery Quality Improvement Project (ACS-NSQIP) database between 2007 and 2014 was performed, identifying 1,979 patients who met inclusion criteria. Patients were subcategorized into three groups based on preoperative nutritional status as defined by albumin levels. Outcome measures for this study included minor postoperative complication(s), major postoperative complication(s), patient mortality, 30-day readmission due to any cause, 30-day readmission related to OVCF, and total length of hospital stay. Analysis of variance was used to evaluate for associations between continuous variables and preoperative albumin levels. Spearman's rank correlation coefficient, chi-square trend, and Kruskal-Wallis analyses were utilized, as appropriate, for categorical variables. A multivariate logistic regression analysis was then conducted to calculate odds ratios with corresponding p values and 95% confidence intervals. RESULTS Functional status showed a statistically significant decline when correlated with preoperative albumin levels. Sepsis, septic shock, pulmonary embolism, reintubation, prolonged intubation, and major complications in general are statistically more likely to occur in patients with hypoalbuminemia. Among minor complications evaluated in this study, only surgical site complications failed to demonstrate a statistical correlation with nutritional status. No statistically significant associations were identified between postoperative outcomes and age, sex, or BMI. CONCLUSIONS Preoperative albumin levels were statistically correlated to the likelihood of minor complications, major complications, or mortality.

BACKGROUND CONTEXT Spine surgery has been identified as a risk factor for prolonged postoperative opioid use. Preoperative prediction of opioid use could improve risk stratification, shared decision-making, and patient counseling before surgery. PURPOSE The primary purpose of this study was to develop algorithms for prediction of prolonged opioid prescription after surgery for lumbar disc herniation. STUDY DESIGN/SETTING Retrospective, case-control study at five medical centers. PATIENT SAMPLE Chart review was conducted for patients undergoing surgery for lumbar disc herniation between January 1, 2000 and March 1, 2018. OUTCOME MEASURES The primary outcome of interest was sustained opioid prescription after surgery to at least 90 to 180 days postoperatively. METHODS Five models (elastic-net penalized logistic regression, random forest, stochastic gradient boosting, neural network, and support vector machine) were developed to predict prolonged opioid prescription. Explanations of predictions were provided globally (averaged across all patients) and locally (for individual patients). RESULTS Overall, 5,413 patients were identified, with sustained postoperative opioid prescription of 416 (7.7%) at 90 to 180 days after surgery. The elastic-net penalized logistic regression model had the best discrimination (c-statistic 0.81) and good calibration and overall performance; the three most important predictors were: instrumentation, duration of preoperative opioid prescription, and comorbidity of depression. The final models were incorporated into an open access web application able to provide predictions as well as patient-specific explanations of the results generated by the algorithms. The application can be found here: https://sorg-apps.shinyapps.io/lumbardiscopioid/ CONCLUSION Preoperative prediction of prolonged postoperative opioid prescription can help identify candidates for increased surveillance after surgery. Patient-centered explanations of predictions can enhance both shared decision-making and quality of care.

Background context En bloc resection and reconstruction (EBR) in patients with spinal malignancy aims to achieve local disease control. This is an invasive procedure with significant alterations of the physiological anatomy and subsequently, the spino-pelvic alignment. Sagittal spinal parameters are useful measurements to objectively identify disproportionate alignment on a radiograph. In the field of spinal deformities, there is increasing evidence for a relationship between sagittal alignment and patient reported outcomes. Purpose To determine sagittal spino-pelvic alignment after EBR in patients with spinal malignancies and the effect of these parameters on surgical and patient reported outcomes. Study Design A retrospective case series. Methods We included 35 patients who underwent EBR for spinal malignancies between 2000 and 2018. Radiographic measurements were performed using semi-automatic software; the parameters included were pelvic incidence (PI), sacral slope, pelvic tilt (PT), global tilt and lumbar lordosis. We calculated PI-based Global Alignment and Proportion (GAP) scores and prospective patient reported outcome scores Patient-Reported Outcome Measurement Information System–Physical Function (PROMIS-PF) were used. Results Twenty-one (60%) patients filled out the PROMIS-PF score at a median of 16 months (Interquartile Range (IQR) 4–108) after surgery with a median score of 39 (IQR 32–42), the median GAP score was 7 (IQR 5–9). Bivariate analysis showed no statistically significant relationship between GAP score and instrumentation failure or need for revision surgery. Multivariable analysis of GAP score and PROMIS-PF score corrected for local disease recurrence showed a statistically significant correlation coefficient of −1.721 (p=.026; 95%CI=−3.216, −0.226). Conclusion In this cohort, all patients had a moderate or severe disproportioned spinal alignment after EBR and reconstruction surgery. The degree of sagittal spino-pelvic misalignment after EBR for spinal malignancies seems to be associated with patient reported health status in terms of PROMIS-PF scores. Further research with a larger patient cohort and standardized imaging and follow-up protocols is necessary in order to accurately use sagittal alignment as a predictive value for instrumentation failure and revision surgery.

Lumbar spinal stenosis is a common condition in the elderly for which costs vary substantially by region. Comparing differences between surgeons from a single institution, thereby omitting regional variation, could aid in identifying factors associated with higher costs and individual drivers of costs. The use of decision aids (DAs) has been suggested as one of the possible tools for diminishing costs and cost variation.(1) To determine factors associated with higher costs for treatment of spinal stenosis in the first year after diagnosis in a single institution; (2) to find individual drivers of costs for providers with higher costs; and (3) to determine if the use of DAs can decrease costs and cost variability.Retrospective cohort study.A total of 10,858 patients in 18 different practices diagnosed with lumbar spinal stenosis between January 2003 and July 2015 in three associated hospitals of a single institution.Mean cost for a patient per provider in US dollars within 1 year after diagnosis of lumbar spinal stenosis.We collected all diagnostic testing, office visits, injections, surgery, and occupational or physical therapy related to lumbar spinal stenosis within 1 year after initial diagnosis. We used multivariable linear regression to determine independent predictors for costs. Providers were grouped in tiers based on mean total costs per patient to find drivers of costs. To assess the DAs effect on costs and cost variability, we matched DA patients one-to-one with non-DA patients.Male gender (β 0.10, 95% confidence interval [CI] 0.05-0.15, p.001), seeing an additional provider (β 0.77, 95% CI 0.69-0.86, p.001), and having an additional spine diagnosis (β 0.79, 95% CI 0.74-0.84, p.001) were associated with higher costs. Providers in the high cost tier had more office visits (p.001), more imaging procedures (p.001), less occupational or physical therapy (p=.002), and less surgery (p=.001) compared with the middle tier. Eighty-two patients (0.76%) received a DA as part of their care; there was no statistically significant difference between the DA group and the matched group in costs (p=.975).Male gender, seeing an additional provider, and having an additional spine diagnosis were independently associated with higher costs. The main targets for cost reduction we found are imaging procedures and number of office visits. Decision aids were not found to affect cost.

Background Context Recurrence of spinal epidural abscess (SEA) after treatment is an important cause of continued morbidity for patients. Purpose The purpose of this study was to identify independent predictors of recurrence of SEA. Study Design/Setting This was a retrospective, case-control study. Patient Sample Patients 18 years or older with a diagnosis of SEA admitted to our hospital system during the study period were included in the study sample. Outcome Measures The outcome measure was recurrence of SEA, defined as a reaccumulation of pus or infected granulation tissue in the epidural space after initial treatment. Methods All patients older than 18 years admitted to our hospital system with a diagnosis of SEA from 1993 to 2016 were identified, and explanatory variables and outcomes were collected retrospectively. Patients 18 years or older diagnosed with SEA were included. We excluded patients whose treatment was initiated at an outside institution. Bivariate and multivariate analyses were performed to identify independent predictors of recurrence. Results We identified 1,053 patients with SEA. We only considered patients to be recurrence-free if they had no documented recurrence with greater than 20 weeks of follow-up. Five hundred thirty-four patients were recurrence-free and 38 had documented recurrence, yielding 572 patients who were included in this analysis. Bivariate and multivariate analyses identified three independent predictors of recurrence: history of intravenous drug use, fecal incontinence or retention, and local spinal wound infection. Conclusions Patients with SEA who have a history of intravenous drug use, bowel dysfunction at presentation, or concurrent local spinal wound infection are at increased risk of disease recurrence. These patients ought to be closely followed up after discharge, with frequent serial imaging and aggressive antibiotic treatment.

Background context Little has been reported regarding the patient-centered quality-of-life (QOL) outcomes after en bloc spondylectomy (ES). Despite lower local recurrence rates, it is unknown whether outcomes justify the surgical morbidity. Purpose The purpose of this study was to report on patient QOL after ES as measured by validated instruments and to identify factors that may predict better postoperative QOL. Study design This is a retrospective case-control study (Level III). Patient sample Thirty-five consecutive patients with mobile spine tumors were included. Twenty-seven patients underwent en bloc resection, whereas 8 patients received definitive radiation and no surgery. Minimum follow-up was 6 months (median, 32 months). Outcome measures The outcome measures were European Quality Group 5-Dimensional Questionnaire (EQ5D), four Patient-Reported Outcome Measurement Information System (PROMIS) short-form metrics, Neck Disability Index, and Oswestry Disability Index (ODI). Methods We performed statistical comparisons between the surgery and radiation groups, of the general US population, and within the study group itself to identify predictors of higher QOL scores. Results We identified a significant difference in QOL between the surgery and radiation groups in only one instrument, PROMIS pain interference, with surgery having more pain interference (15.7 vs. 10.1, p=.04). For most metrics, including EQ5D, pain interference, pain behavior, and ODI, scores were around one standard deviation worse than the US population mean. Multivariable linear regression for each instrument demonstrated that preoperative factors such as better performance status, tumor location in the cervical spine, lack of mechanical back or neck pain, and shorter fusion span were independently predictive of better QOL scores. Postoperative factors such as poor performance status, chronic narcotic use, and local recurrence were more dominant than preoperative factors in predicting worse QOL. Conclusions Patients may experience more pain interference after surgery as opposed to definitive radiotherapy, but we did not identify a difference for most metrics. Quality of life in our study group was significantly worse than the general population for most metrics. Cervical tumors, lack of mechanical pain, better baseline performance status, and less extensive surgery predict better QOL after surgery.

Background Context Acute fixed cervical kyphosis may be a rare presentation of conversion disorder, psychogenic dystonia, and potentially as a side effect from typical antipsychotic drugs. Haldol has been associated with acute dystonic reactions. In some cases, rigid deformities ensue. We are reporting a case of a fixed cervical kyphosis after the use of Haldol. Purpose To present a case of a potential acute dystonic reaction temporally associated with Haldol ingestion leading to fixed cervical kyphosis. Study design This is a case report. Methods A patient diagnosed with bipolar disorder presented to the emergency room several times with severe neck pain and stiffness. The neck appeared fixed in flexion with extensive osteophyte formation over a 3-month period. Results The patient's condition was resolved by a posterior-anterior-posterior surgical approach. It corrected the patient's cervical curvature from 88° to 5°. Conclusions Acute dystonic reactions have the potential to apply enough pressure on bone to cause rapid osteophyte formation.

Background context Epithelioid hemangioma (EH) of bone is a benign vascular tumor that can be locally aggressive. It rarely arises in the spine, and the optimum management of EH of the vertebrae is not well delineated. Purpose The report describes our experience treating six patients with EH of the spine in an effort to document the treatment of the rare spinal presentation. Study design This study is designed as a retrospective cohort study. Patient sample A continuous series of patients with the diagnosis of EH of the spine who presented at our institution. Outcome measures The clinical and radiographic follow-up of the patient population is documented. Methods The Bone Sarcoma Registry at our institution was used to obtain a list of all patients diagnosed with EH of the spine. Medical records, radiographs, and pathology reports were retrospectively reviewed in all cases. Only biopsy-proven cases were included. Results The six patients included five men and one woman who ranged in age from 20 to 58 years (with an average age of 40 years). The follow-up available for all six patients ranged from 6 to 115 (average 46.8) months. All patients presented with lytic vertebral body lesions. Five patients presented with pain secondary to their tumor, and the tumor in the sixth patient was found incidentally during the workup for a herniated disc. Three patients required surgical management for instability secondary to the destructive nature of their tumors, and two other patients required emergent decompression secondary to spinal cord compression by the tumor. The sixth patient was treated expectantly after biopsy confirmation. Three patients received postoperative radiation therapy as gross tumor remained after surgery. Three patients had gross total resections and did not receive postoperative radiation. Preoperative embolization was used in four patients. One patient continued to have back pain after surgery and radiation and another continued to have ataxia after surgery and radiation. No tumor locally recurred or progressed. Conclusions Our data suggest that EH of the spine can be locally aggressive and lead to instability and cord compression. Surgery is required in such instances; however, observation should be considered in patients without instability or cord compression.

Background context Because of the low incidence, treatment recommendations for spinal osteosarcoma are guided by the results of small series and case reports. Many include patients who presented for treatment over the course of three to four decades. Purpose The goal of this investigation was to report the treatments, results, and overall survivorship of 26 patients treated for osteosarcoma of the spine at a single institution. Study design Retrospective prognostic series (Level III evidence). Patient sample Twenty-six patients treated at a single center for osteosarcoma of the spine over a 26-year period. Outcome measures Estimation of patient survival, local recurrence, and the presence of metastatic disease. Methods We performed a retrospective review of cases of osteosarcoma involving the spine treated at our institution between 1982 and 2008. Medical charts, radiology reports, pathology reports, and operative notes were reviewed for all patients. Available imaging studies were also reviewed. The log-rank test was used to compare baseline differences between groups. Survivorship analysis was performed using Kaplan–Meier methodology. The effect of Paget osteosarcoma, type of resection, presence of local recurrence, tumor size, surgical margins, and metastases on overall survival were also investigated using the log-rank test. Results Twenty-six patients were included for review in this study. Twenty individuals were treated surgically, and 24 were treated with radiation with a mean dose of 62.2 Gy (range 20–84.7 Gy). Twenty-five patients received chemotherapy. Of those treated surgically, seven received en bloc resection. The median overall survival for all patients in our series was 29.5 months (standard error 14.7, 95% confidence interval 0.6–58). Local recurrence developed in 7 patients (27%), and metastasis occurred in 16 individuals (62%). Patients with Paget osteosarcoma had worse overall survival (p Conclusions Results presented here confirm a poor prognosis for patients with spinal osteosarcoma. Although combination therapies, including surgery, chemotherapy, and high-dose radiation, achieve adequate short-term survival, the 5-year mortality rate remains high.