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Systematic Review OBJECTIVE: - The objective of this study was to summarize and assess the current literature evaluating non-operative treatments for patients with Modic changes (MC) and low back pain (LBP).- A systematic review was conducted in accordance with PRISMA guidelines. The PubMed database was searched from its inception until May 1, 2022 for studies evaluating Modic changes and clinical outcomes. Key findings, treatment details, and patient information were extracted from included studies. Study quality was assessed using the Newcastle-Ottawa Scale.- Eighteen studies were included in this review, encompassing a total of 2,452 patients, 1,713 of whom displayed baseline MC. Seventy-eight percent of studies were high quality. Of included studies, 2 evaluated antibiotics, 5 evaluated steroid injections, 6 evaluated conservative therapies and 5 evaluated other treatment modalities. Antibiotics and bisphosphonates improved treatment in patients with MC. Patients with MC without disc herniation benefited from conservative therapy, while those with MC-I and disc herniation experienced poorer improvement. Significant variability exists in reported outcomes following steroid injections.- Non-operative therapy may provide patients with MC with significant benefits. Patients may benefit from therapies not traditionally utilized for LBP such as antibiotics or bisphosphonates, but conservative therapy is not recommended for patients with concomitant MC and disc herniation. The large variation in follow-up times and outcome measures contributes to significant heterogeneity in studies and inability to predict long-term patient outcomes. More long-term studies are needed to assess non-operative treatments for LBP in patients with MC.

To compare clinical outcomes of patients diagnosed with degenerative scoliosis undergoing short-segment versus long-segment spinal fusion.A retrospective cohort study was conducted of patients with degenerative thoracolumbar scoliosis undergoing elective spinal fusion at a single academic medical center. Cohorts were divided into short-segment (3) or long-segment (≥3) groups.A total of 197 patients (122 short, 75 long) were included. Patients undergoing short-segment fusion more frequently presented with radiculopathy (P0.001) and had greater baseline visual analog scale (VAS) leg scores (P0.001). Patients with long-segment fusions had longer hospital length of stay (short, 3.82 ± 2.98 vs. long, 7.40 ± 6.85 days; P0.001), lower home discharge rates (short, 80.3% vs. long, 51.8; P = 0.003), higher revision surgery rates (short, 10.77% vs. long, 25.3%; P = 0.012), and greater percentage curve correction (short, 37.3% ± 25.9% vs. long, 45.1% ± 23.9%; P = 0.048). No significant differences were noted in postoperative complication rates (short, 1.64% vs. long, 5.33%; P = 0.143). At 1 year, patients with long fusions had worse ΔOswestry Disability Index (ODI) (P = 0.024), ΔVAS leg score (P = 0.002), and VAS leg minimum clinically important difference % (P = 0.003). Multivariate regression found that short-segment fusions were associated with greater improvements in ODI (P = 0.029), Physical Component Summary-12 (P = 0.024), and VAS leg score at 1 year (P = 0.002).Patients undergoing short-segment fusions more frequently presented with radiculopathy and had higher preoperative VAS leg scores compared with those receiving long constructs. Short-construct fusions in appropriately selected patients may provide satisfactory improvements in patient-reported outcome measures, particularly ΔODI and ΔVAS leg score, and mitigate hospital length of stay, revision surgery rates, and nonhome discharge.

Anterior cervical discectomy and fusion (ACDF) is commonly performed in patients with radiculopathy and myelopathy. Although the goal of surgery in patients with radiculopathy is to improve function and reduce pain, patients with myelopathy undergo surgery to halt disease progression. Although the expectations between these preoperative diagnoses are generally understood to be disparate by spine surgeons, there is limited literature demonstrating their discordant outcomes.To compare improvements in patient reported outcome measures (PROMs) for patients undergoing ACDF for myelopathy or radiculopathy. Secondarily, we analyzed the proportion of patients who attain the minimum clinically important difference (MCID) postoperatively using thresholds derived from radiculopathy, myelopathy, and mixed cohort studies.Single institution retrospective cohort study PATIENT SAMPLE: Patients undergoing primary, elective ACDF with a preoperative diagnosis of radiculopathy or myelopathy and a complete set of preoperative and one-year postoperative PROMs.Outcome measures included the following PROMs: Short-Form 12 Physical Component (PCS-12) and Mental Component (MCS-12) scores, the Visual Analog Scale (VAS) Arm score, and the Neck Disability Index (NDI). Hospital readmissions and revision surgery were also collected and evaluated.Patients undergoing an ACDF from 2014 to 2020 were identified and grouped based on preoperative diagnosis (radiculopathy or myelopathy). We utilized "general MCID" thresholds from a cohort of patients with degenerative spine conditions, and "specific MCID" thresholds generated from cohorts of patients with myelopathy or radiculopathy, respectively. Multivariate linear regressions were performed for delta (∆) PROMs and multivariate logistic regressions were performed for both general and specific MCID improvements.A total of 798 patients met inclusion criteria. Patients with myelopathy had better baseline function and arm pain (MCS-12: 49.6 vs 47.6, p=.018; VAS Arm: 3.94 vs 6.02, p.001; and NDI: 34.1 vs 41.9, p.001), were older (p.001), had more comorbidities (p=.014), more levels fused (p.001), and had decreased improvement in PROMs following surgery compared to patients with radiculopathy (∆PCS-12: 4.76 vs 7.21, p=.006; ∆VAS Arm: -1.69 vs -3.70, p.001; and ∆NDI: -11.94 vs -18.61, p.001). On multivariate analysis, radiculopathy was an independent predictor of increased improvement in PCS-12 (β=2.10, p=.019), ∆NDI (β=-5.36, p.001), and ∆VAS Arm (β=-1.93, p.001). Radiculopathy patients were more likely to achieve general MCID improvements following surgery (NDI: Odds ratio (OR): 1.42, p=.035 and VAS Arm: OR: 2.98, p.001), but there was no difference between patients with radiculopathy or myelopathy when using radiculopathy and myelopathy specific MCID thresholds (MCS-12: p=.113, PCS-12: p=.675, NDI: p=.108, and VAS Arm: p=.314).Patients undergoing ACDF with myelopathy or radiculopathy represent two distinct patient populations with differing treatment indications and clinical outcomes. Compared to radiculopathy, patients with myelopathy have better baseline function, decreased improvement in PROMs, and are less likely to reach MCID using general threshold values, but there is no difference in the proportion reaching MCID when using specific threshold values.IRB.

To determine the predictive value of the modified Frailty Index (mFI) in evaluating sarcopenia and clinical outcomes in patients undergoing 1-level or 2-level transforaminal lumbar interbody fusion (TLIF).Patients who underwent a 1-level or 2-level TLIF between 2012 and 2020 were retrospectively identified. Frailty was compared among groups using mFI, and sarcopenia was classified by the psoas muscle cross-sectional area. Bivariate statistics compared demographics, comorbidities, and clinical outcomes. A linear regression model was developed using the Charlson Comorbidity Index (CCI) or mFI as independent variables to determine potential predictors for improvement in 1-year patient-reported outcomes.Of 488 included patients, 60 were severely frail and 60 patients had sarcopenia, but sarcopenia was not associated with patient frailty (P = 0.469). Severely frail patients had worse baseline Oswestry Disability Index (ODI) (P0.001), Mental Component Score-12 (P = 0.001), and Physical Component Score-12 (P0.001), and worse improvement in ODI (P = 0.037), Physical Component Score-12 (P0.001), and visual analog scale (VAS) back (P = 0.007). mFI was an independent predictor of poorer improvement in VAS back and ODI, whereas age + CCI in addition predicted poorer improvement in VAS leg. Patients with higher mFI experienced longer length of stay, less frequent home discharge, and higher rates of complications, but similar readmission and reoperation rates.Frailer patients experience poorer improvement in back pain, physical functioning, and disability after TLIF. mFI and the combination of age and CCI comparably predict patient-reported outcomes but do not correlate to baseline sarcopenia. Frailty increased the risk of complications, length of hospital stay, and risk of nonhome discharge.

Indications for revision lumbar fusion are variable, but include recurrent stenosis (RS), adjacent segment disease (ASD), and pseudarthrosis. The efficacy of revision lumbar fusion has been well established, but their outcomes compared to primary procedures is not well documented.The purpose of this study was to compares surgical and clinical outcomes between (1) revision and primary lumbar fusion, (2) revision lumbar fusion based on indication (ASD, pseudarthrosis, or RS), and (3) revision lumbar fusion based on whether the index procedure included an isolated decompression or decompression with fusion.Retrospective single-institution cohort study.Four thousand six hundred seventy-one consecutive lumbar fusions from 2011 to 2021, of which 892 (23.6%) were revision procedures. The indication for revision procedures included 502 (56.3%) for ASD, 153 (17.2%) for pseudarthrosis, and 237 (26.6%) for RS. Of the 892 revision procedures, 694 (77.8%) underwent an index fusion while 198 (22.2%) underwent an index decompression without fusion.Hospital readmissions, all-cause reoperation, need for subsequent revision and patient reported outcome measures (PROMs) at baseline, 3-months postoperatively, and 1-year postoperatively, including the Mental Health Component score (MCS-12) and Physical Health Component score (PCS-12) of the Short Form 12 survey, the Oswestry Disability Index (ODI), and the Visual Analog Scale (VAS) for Back and Leg pain.Patient demographics, comorbidities, surgical characteristics, and outcomes were collected from electronic medical records. Twenty-eight percent of patients had preoperative and postoperative PROMs. A delta PROM score was calculated for the 3-month and 1-year postoperative timepoints, which was the change from the preoperative to postoperative value. Univariate comparisons were performed to compare revision fusions to primary fusions. Multivariate logistic regression was performed for all-cause reoperation and subsequent revision surgery, while multivariate linear regression was performed for ∆PROMs at 3-months and 1-year. Revision procedures were then separately regrouped based on indication for revision fusion and whether they underwent a fusion for their index procedure. Univariate comparisons and multivariate linear regressions for ∆PROMs were then repeated based on the new groupings.There was no difference in hospital readmission rate (5.38% vs. 4.60%, p=.372) or length of stay (4.10 days vs. 3.94 days, p=.129) between revision and primary lumbar fusion, but revision fusions had a higher rate of all-cause reoperation (16.1% vs. 11.2%, p.001) and subsequent revision (13.7% vs. 9.71%, p=.001), which was confirmed on multivariate logistic regression (Odds Ratio (OR): 1.42, p=.001 and OR: 1.37, p=.007, respectively). On multivariate analysis, a revision procedure was an independent risk factor for worse improvement ∆ODI, ∆VAS Back, ∆VAS Leg, and ∆PCS-12 and 1-year postoperatively. Regardless of the indication for revision lumbar fusion, patients significantly improved in the 3-month and 1-year postoperative PCS-12, ODI, VAS Back, and VAS Leg, with the exception of the 3-month PCS-12 for pseudarthrosis (p=.620). Patients undergoing revision for ASD had significantly worse 1-year postoperative PCS-12 (32.3 vs. Pseudarthrosis: 35.6 and RS: 37.0, p=.026), but there were no differences in ∆PROMs. There was no difference in hospital readmission, all-cause reoperation, or subsequent revision based on whether a patient had an index lumbar fusion or isolated decompression. Multivariate linear regression analysis found that a surgical indication of pseudarthrosis was a significant predictor of decreased improvement in 3-month ∆VAS Leg (ref: ASD, β=2.26, p=.036), but having an index fusion did not significantly predict worse improvement in ∆PROMs when compared to isolated decompressions.Revision lumbar fusions had a higher rate of reoperation and subsequent revision surgery when compared to primary lumbar fusions, but there were no difference in hospital readmission rates. Patients undergoing revision lumbar fusion experience improvements in all patient reported outcome measures, but their baseline, postoperative, and magnitude of improvement are worse than primary procedures. Regardless of whether the lumbar fusion is a primary or revision procedure, all patients have significant improvements in pain, disability and physical function. Further, the indication for the revision procedure is not correlated with the expected magnitude of improvement in patient reported outcomes. Finally, no differences in baseline, postoperative, and ∆PROMs for revision fusions were identified when stratifying by whether the patient had an index decompression or fusion.

To determine the effect of operative duration on the rate of postoperative symptomatic venous thromboembolic (VTE) events in patients undergoing thoracolumbar spine fusion.We identified all thoracolumbar spine fusion patients between 2012 and 2021. Operative duration was defined as time from skin incision to skin closure. A 1:1 propensity match was conducted incorporating patient and surgical characteristics. Logistic regression was performed to assess predictors of postoperative symptomatic VTE events. A receiver operating characteristic curve was created to determine a cutoff time for increased likelihood of VTE.We identified 101 patients with VTE and 1108 patients without VTE. Seventy-five patients with VTE were matched to 75 patients without VTE. Operative duration (339 vs. 262 minutes, P = 0.010) and length of stay (5.00 vs. 3.54 days, P = 0.008) were significantly longer in patients with a VTE event. Operative duration was an independent predictor of VTE on multivariate regression (odds ratio: 1.003, 95% confidence interval: 1.001-1.01, P = 0.021). For each additional hour of operative duration, the risk of VTE increased by 18%. A cutoff time of 218 minutes was identified (area under the curve [95% confidence interval] = 0.622 [0.533-0.712]) as an optimal predictor of increased risk for a VTE event.Operative duration significantly predicted symptomatic VTE, especially after surgical time cutoff of 218 minutes. Each additional hour of operative duration was found to increase VTE risk by 18%. We also identify the impact of VTE on 90-day readmission rates, suggesting significantly higher costs and opportunity for hospital acquired conditions, in line with prior literature.

To compare rates of different fusion techniques using a nationwide database over the last decade and identify differences in complications and readmissions based on fusion technique.All elective, single-level lumbar fusions performed by orthopaedic surgeons from 2011 to 2020 were identified from the American College of Surgeons National Surgical Quality Improvement Program. Rates of lumbar fusion technique posterolateral decompression and fusion [PLDF], combined transforaminal lumbar interbody fusion and PLDF, anterior lumbar or lateral lumbar interbody fusion [ALIF/LLIF], and combined ALIF/LLIF and PLDF were recorded, and 30-day complications and readmissions were compared. Secondary analysis included multiple logistic regression to determine independent predictors of each outcome.Inclusion criteria were met by 28,413 fusions: 8749 (30.8%) PLDFs, 11,973 (42.1%) transforaminal lumbar interbody fusions, 4769 (16.8%) ALIF/LLIFs, and 2922 (10.3%) combined ALIF/LLIF and PLDFs. The number of fusions increased over time with 1227 fusions performed in 2011 and 3958 fusions performed in 2019. Interbody fusions also increased over time with a subsequent decrease in PLDFs (39.0% in 2011, 25.2% in 2020). Patients were more likely to be discharged home over the course of the decade (85.4% in 2011, 95.0% in 2020). No difference was observed between the techniques regarding complications or readmissions. The modified 5-item frailty index was predictive of complications (odds ratio, 2.05; P = 0.001) and readmissions (odds ratio, 2.61; P0.001).Lumbar fusions have continued to increase over the last decade with an increasing proportion of interbody fusions. Complications and readmissions appear to be driven by patient comorbidity and not fusion technique.

The purpose of this retrospective cohort study was to evaluate the effect of tranexamic acid (TXA) on reducing perioperative blood loss and length of stay after transforaminal lumbar interbody fusion (TLIF). Spine surgery is associated with the potential for significant blood loss, and adequate hemostasis is essential to visualizing crucial structures during the approach and procedure. Although TXA use has been extensively studied in the pediatric and adult spinal deformity literature, there is a dearth of literature on its efficacy in reducing blood loss for patients who undergo 1- to 3-level TLIF.All patients requiring 1- to 3-level TLIF who received a preoperative loading dose of TXA were grouped and compared with patients who didn't receive TXA. Demographic, surgical, and laboratory values were collected and analyzed. Continuous and categorical variables were analyzed with χPatients who received preoperative TXA had more comorbidities (P = 0.006), longer surgery length (P0.001), and longer length of stay (P = 0.004). TXA was independently associated with a decreased day 0, 1, 2, and total drain output (P0.001, P = 0.001, P = 0.007, P0.001, respectively), but was not associated with a change in EBL, total blood loss, or length of stay.The application of preoperative TXA for patients undergoing 1- to 3-level TLIF reduced drain output in the first 2 postoperative days, but it did not affect hospital length of stay, total blood loss, or EBL.

1) To analyze the effect of operative sequence (anterior cervical discectomy and fusion [ACDF] first or rotator cuff repair [RCR] first) on surgical outcomes after both procedures for patients with dual shoulder-spine injuries and 2) to determine how operative sequence affects patient-reported outcome measures (PROMs) after surgery.Patients18 years of age who underwent primary ACDF and primary RCR at our institution were retrospectively identified. Only patients with overlapping symptoms before the first procedure were included. Patients were divided into 2 cohorts (ACDF first or RCR first). Patient demographics, surgical characteristics, surgical outcomes, and PROMs were compared between groups. Multivariate linear regression models were developed to determine if operative order was predictive of improvements in PROM scores at the 1-year postoperative point after the second procedure. Alpha was set at P0.05.Of the 85 patients included, 44 patients (51.8%) underwent ACDF first, whereas 41 patients (48.2%) underwent RCR first. There were no significant differences in the rate of 90-day readmission, spine reoperations, and rotator cuff reoperations between groups (all, P0.05). Multivariate linear regression showed that undergoing an ACDF first was not a significant predictor of Δ Mental Component Score of the Short-Form 12 (β = -2.78; P = 0.626) and Δ Physical Component Score of the Short-Form 12 (β = 7.74; P = 0.077) at the 1-year postoperative point after the second procedure.For patients with dual shoulder-spine injuries who are appropriate surgical candidates, undergoing ACDF first compared with RCR first does not result in significant differences in clinical surgical or patient-reported outcomes.

To determine whether operative duration of anterior cervical discectomy and fusion (ACDF) significantly affects patient-reported outcome measures (PROMs) 90 days after surgery and at 1-year follow-up.Patients who underwent primary 1-level to 4-level ACDF were retrospectively identified. Demographic data and PROMs were collected through chart review. Patients were split into short, medium, and long tertiles based on procedure duration. PROM surveys were administered preoperatively as baseline measurements, at initial follow-up (between 60 and 120 days postoperatively), and at 1 year postoperatively. Outcomes included Neck Disability Index, Short-Form 12 Physical Component Score (PCS-12), Short-Form 12 Mental Component Score, visual analog scale (VAS) neck score, and VAS arm score.Significant short-term improvements were found across all groups for all PROMs. All groups showed long-term improvements in Short-Form 12 Mental Component Score, PCS-12, Neck Disability Index, VAS neck score, and VAS arm score, with the exception of the medium-duration group in PCS-12 (P = 0.093). On multivariate analysis, short-duration procedures predicted better improvement in VAS neck score (β = -1.01; P = 0.012) and VAS arm score (β = -1.38; P = 0.002) compared with long-duration procedures, whereas medium-duration procedures resulted in better improvement in VAS arm score (β = -1.00; P = 0.011). Further, short and medium duration was a predictor of decreased length of hospital stay (β = -0.67, P = 0.001 and β = -0.59, P = 0.001, respectively) compared with long-duration procedures.All groups improved after ACDF regardless of surgical duration. Further, surgical duration was not a predictor of differing improvement in physical function or disability.

Determining important links between medical comorbidities and cervical spine degenerative disc disease (DDD) will help elucidate pathomechanisms of disc degeneration. Electronic medical records and magnetic resonance imaging were retrospectively reviewed to evaluate 799 patients assessed for cervical spine pathology. Bivariate analysis identified older age, diabetes, ASA class, cancer, COPD, depression, hypertension, hypothyroidism, Medicare status, peripheral vascular disease, history of previous cervical spine surgery, smoking, and lower median household income as having strong associations with increased cumulative grade of cervical spine DDD. This study provides evidence suggesting aging and accumulation of medical comorbidities influence severity of cervical spine DDD.

BACKGROUND CONTEXT Previous degenerative disc disease (DDD) literature has primarily focused on lumbar DDD. However, biomechanics of the cervical and lumbar spine are different. Cervical spine intervertebral discs (IVDs) are designed to withstand compression forces better than lumbar spine IVDs, but they are less equipped to tolerate bending stresses when compared to the lumbar spine. Therefore, it is unclear if co-morbidities associated with lumbar DDD are also correlated with cervical disc disease, and to our knowledge this has not previously been studied. PURPOSE Our primary objective was to determine if diabetics experience cervical DDD at a higher rate than non-diabetics. Our secondary objectives were to assess: 1) whether glycemic control (insulin use, blood glucose levels >200 and HgA1c levels >8.0%) or 2) other medical comorbidities were associated with cervical DDD. STUDY DESIGN/SETTING Retrospective cohort study in a tertiary care center. PATIENT SAMPLE A total of 308 diabetic and 315 non-diabetic patients. OUTCOME MEASURES Suzuki scoring of cervical spine intervertebral disc on MRI (0-3). METHODS Patients who underwent cervical spine MRI at our university for any reason between 2011-2019 were identified. A random group of 308 diabetic and 315 non-diabetic patients’ health data was extracted from the electronic medical record. Each intervertebral disc graded on MRI was scored from C2-T1 based on the Suzuki intervertebral disc score (0-3) in a blinded fashion. For univariate analysis, a one-sided Mann-Whitney test for non-parametric data was used to assess for an association between diabetes and DDD risk. The chi-square or Fisher's Exact test identified associations between comorbidities and Suzuki scores. All tests were adjusted for multiple comparisons using the Benjamini-Hochberg method. Multivariate data was analyzed using a best fit model. RESULTS Univariate analysis identified age, diabetes, hypertension, hypothyroidism, ASA class, cancer, pulmonary disease (COPD), number of previous cervical spine surgeries, peripheral vascular status, smoking and Medicare insurance as correlating with worse cumulative cervical spine disc disease (p 200 and HgA1c levels >8.0% were not associated with increased DDD in diabetics (p>0.05). On multivariate analysis, age and ASA class showed the highest correlation with cervical DDD. CONCLUSIONS Cervical spine DDD is multifactorial. We found diabetes diagnosis to be strongly correlated with cervical spine DDD. Additionally, multivariate analysis identified age and ASA class as best correlated with cervical DDD. Interestingly, BMI and poor glycemic control was not associated with cervical DDD. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Neck and back pain caused by intervertebral disc (IVD) degeneration is a frequent cause of referral to spine surgeons. This is a multifactorial disease process caused by aging, injury, obesity, and mechanical stress. Recently, an association between IVD degeneration and diabetes has been identified, but the mechanisms underlying this relationship are unclear. Furthermore, the effects of insulin levels on cytokines known to be elevated in diabetics have not previously been delineated. Uncontrolled diabetes results in chronic systemic inflammation with increased circulating levels of IL-6 and IL-18. Therefore, this study was designed to characterize the metabolic responses of normal IVDs to stimulation with IL-6 and IL-18 under normal and low insulin conditions using a validated rat tail whole-organ IVD explant model. STUDY DESIGN/SETTING Tissue harvest and culture: under IACUC approval, tails were collected from humanely euthanized skeletally mature Sprague Dawley rats (n=6). Whole-organ IVD explants (n=48) were randomly assigned to either 1 µg/ml low insulin (LI) or 10 µg/ml normal insulin (NI) and treated with IL-6 (6), IL-18 (18), or both (B) at 50ng/ml each (n=6/group). A subset of discs (n=24) was subject to injury (I) with a 20G needle penetrating the annulus fibrosus to the center of the nucleus pulposus and 0.5 ml aspiration. Uninjured (U) explants without cytokine stimulation served as negative controls (N). The explants were cultured for 12 days with media collected on days 3, 6, 9, and 12 for analysis. Media Analyses: Media were analyzed for NO, PGE2, MIP-1α, IL-10, MCP-1,GRO-KC, and IL-13 using commercially available assays according to the manufacturer's protocol. Statistical Analysis: Significant differences between groups were assessed using a t-Test or Rank Sum test based on the normality of the data with significance set at p RESULTS The LI-6, LI-18, and LI-B groups had higher (p CONCLUSIONS Our results suggest that injured and uninjured IVDs have unique responses to stimulation with diabetes-related cytokines and that insulin levels may have direct effects on mediators of chronic inflammation associated with diabetes. Thus, well-managed diabetics being treated with an appropriate insulin regimen may be at decreased risk of developing degenerative disc disease. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.