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BACKGROUND Traumatic spinal cord injury (SCI) is a serious public health problem. Outcomes are determined by severity of immediate injury, mitigation of secondary downstream effects, and rehabilitation. This study aimed to understand how the center type a patient presents to and whether they are transferred influence management and outcome. METHODS The National Trauma Data Bank was used to identify patients with SCI. The primary objective was to determine association between center type, transfer, and surgical intervention. A secondary objective was to determine association between center type, transfer, and surgical timing. Multivariable logistic regression models were fit on surgical intervention and timing of the surgery as binary variables, adjusting for relevant clinical and demographic variables. RESULTS There were 11,744 incidents of SCI identified. A total of 2,883 patients were transferred to a Level I center and 4,766 presented directly to a level I center. Level I center refers to level I trauma center. Those who were admitted directly to level I centers had a higher odd of receiving a surgery (odds ratio, 1.703; 95% confidence interval, 1.47-1.97; p < 0.001), but there was no significant difference in terms of timing of surgery. Patients transferred into a level I center were also more likely to undergo surgery than those at a level II/III/IV center, although this was not significant (odds ratio, 1.213; 95% confidence interval, 0.099-1.48; p = 0.059). CONCLUSION Patients with traumatic SCI admitted to level I trauma centers were more likely to have surgery, particularly if they were directly admitted to a level I center. This study provides insights into a large US sample and sheds light on opportunities for improving pre hospital care pathways for patients with traumatic SCI, to provide the timely and appropriate care and achieve the best possible outcomes. LEVEL OF EVIDENCE Care management, Level IV.

OBJECTIVEStereotactic body radiation therapy (SBRT) offers efficient, noninvasive treatment of spinal neoplasms. Single-fraction (SF) high-dose SBRT has a relatively narrow therapeutic window, while hypofractionated delivery of SBRT may have an improved safety profile with similar efficacy. Because the optimal approach of delivery is unknown, the authors examined whether hypofractionated SBRT improves pain and/or functional outcomes and results in better tumor control compared with SF-SBRT.METHODSThis is a single-institution retrospective study of adult patients with spinal metastases treated with SF- or three-fraction (3F) SBRT from 2008 to 2019. Demographics and baseline characteristics, radiographic data, and posttreatment outcomes at a minimum follow-up of 3 months are reported.RESULTSOf the 156 patients included in the study, 70 (44.9%) underwent SF-SBRT (median total dose 1700 cGy) and 86 (55.1%) underwent 3F-SBRT (median total dose 2100 cGy). At baseline, a higher proportion of patients in the 3F-SBRT group had a worse baseline profile, including severity of pain (p < 0.05), average use of pain medication (p < 0.001), and functional scores (p < 0.05) compared with the SF-SBRT cohort. At the 3-month follow-up, the 3F-SBRT cohort experienced a greater frequency of improvement in pain compared with the SF-SBRT group (p < 0.05). Furthermore, patients treated with 3F-SBRT demonstrated a higher frequency of improved Karnofsky Performance Scale (KPS) scores (p < 0.05) compared with those treated with SF-SBRT, with no significant difference in the frequency of improvement in modified Rankin Scale scores. Local tumor control did not differ significantly between the two cohorts.CONCLUSIONSPatients who received spinal 3F-SBRT more frequently achieved significant pain relief and an increased frequency of improvement in KPS compared with those treated with SF-SBRT. Local tumor control was similar in the two groups. Future work is needed to establish the relationship between fractionation schedule and clinical outcomes.

Study design Literature review. Objectives It has been reported that 2.4–3.7% of all blunt trauma victims suffer some element of cervical spine fracture, with the majority of these patients suffering from C3-7 (subaxial) involvement. With the improvement of first-response to trauma in the community, there are an increasing number of patients who survive their initial trauma and thus arrive at the hospital in need of further evaluation, stabilization, and management of these injuries. Methods A comprehensive literature review compiled all relevant data on the biomechanics, imaging, evaluation, and medical and surgical management strategies for subaxial cervical spine fractures. Results After review of the current literature on subaxial cervical spine biomechanics, imaging characteristics, evaluation strategies and surgical and orthopedic management techniques, the authors created a comprehensive review and protocol for management of subaxial cervical spine fractures. Conclusions The subaxial cervical spine is biomechanically and anatomically unique from the remainder of the spinal axis. Evaluation of subaxial cervical spine injuries is nuanced, and improper management of these injuries can lead to significant patient morbidity and even death. This provides a comprehensive review combining anatomy, imaging characteristics, evaluation strategies, and surgical and orthopedic management principles for subaxial cervical spine fractures.

STUDY DESIGN Retrospective cohort study. OBJECTIVE To determine whether type of intraoperative blood transfusion used is associated with increased incidence of postoperative delirium after complex spine fusion involving five levels or greater. SUMMARY OF BACKGROUND DATA Postoperative delirium after spine surgery has been associated with age, cognitive status, and several comorbidities. Intraoperative allogenic blood transfusions have previously been linked to greater complication risks and length of hospital stay. However, whether type of intraoperative blood transfusion used increases the risk for postoperative delirium after complex spinal fusion remains relatively unknown. METHODS The medical records of 130 adult (≥18 years old) spine deformity patients undergoing elective, primary complex spinal fusion (more than or equal to five levels) for deformity correction at a major academic institution from 2010 to 2015 were reviewed. We identified 104 patients who encountered an intraoperative blood transfusion. Of the 104, 15 (11.5%) had Allogenic-only, 23 (17.7%) had Autologous-only, and 66 (50.8%) had Combined transfusions. The primary outcome investigated was the rate of postoperative delirium. RESULTS There were significant differences in estimated blood loss (Combined: 2155.5 ± 1900.7 mL vs. Autologous: 1396.5 ± 790.0 mL vs. Allogenic: 1071.3 ± 577.8 mL vs. None: 506.9 ± 427.3 mL, P

Objective Previous studies have identified the impact of affective disorders on preoperative and postoperative perception of pain. However, there is a scarcity of data identifying the impact of affective disorders on postdischarge narcotic refills. The aim of this study was to determine whether patients with affective disorders have more narcotic refills after complex spinal fusion for deformity correction. Methods The medical records of 121 adult (≥18 years old) spine deformity patients undergoing elective, primary complex spinal fusion (≥5 level) for deformity correction at a major academic institution from 2010 to 2015 were reviewed. Patient demographics, comorbidities, intraoperative and postoperative complication rates, baseline and postoperative patient-reported pain scores, ambulatory status, and narcotic refills were collected for each patient. The primary outcome was the rate of 6-week and 3-month narcotic refills. Results Of the 121 patients, 43 (35.5%) had a clinical diagnosis of anxiety or depression (affective disorder) (AD n = 43; No-AD n = 78). Preoperative narcotic use was significantly higher in the AD cohort (AD 65.9% vs. No-AD 37.7%, P = 0.0035). The AD cohort had significantly higher pain scores at baseline (AD 6.5 ± 2.9 vs. No-AD 4.7 ± 3.1, P = 0.004) and at the first postoperative pain score reported (AD 6.7 ± 2.6 vs. No-AD 5.6 ± 2.9, P = 0.049). However, there were no significant differences in narcotic refills at 6 weeks (AD 34.9% vs. No-AD 25.6%, P = 0.283) and 3 months (AD 23.8% vs. No-AD 17.4%, P = 0.411) after discharge between the cohorts. Conclusions Our study suggests that whereas spinal deformity patients with affective disorders may have a higher baseline perception of pain and narcotic use, the impact of affective disorders on narcotic refills at 6 weeks and 3 months may be minimal after complex spinal fusion.

Background The use of postoperative cervical collars following cervical fusions is common practice. Its use has been purported to improve fusion rates and outcomes. There is a paucity in the strength of evidence to support its clinical benefit. Our objective is to critically evaluate the published literature to determine the strength of evidence supporting the use of postoperative cervical collar use following cervical fusions. Methods A systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (also known as PRISMA) was performed. An online search using Medline and Cochrane Central Register of Controlled Trials databases was used to query prospective and retrospective clinical trials evaluating cervical fusions with or without postoperative collar. Results The search identified 894 articles in Medline and 65 articles in the Cochrane database. From these articles, 130 were selected based on procedure and collar use. Only 3 studies directly compared between collar use and no collar use. Our analysis of the mean improvement in neck disability index scores and improvement over time intervals did not show a statistically significant difference between collar versus no collar (P = 0.86). Conclusions We found no strong evidence to support the use of cervical collars after 1- and 2-level anterior cervical discectomy and fusion procedures, and no studies comparing collar use and no collar use after posterior cervical fusions. Given the cost and likely impact of collar use on driving and the return to work, our study shows that currently there is no proven benefit to routine use of postoperative cervical collar in patients undergoing 1- and 2-level anterior cervical discectomy and fusion for degenerative cervical pathologies.

OBJECTIVEIn the United States, healthcare expenditures have been soaring at a concerning rate. There has been an excessive use of postoperative radiographs after spine surgery and this has been a target for hospitals to reduce unnecessary costs. However, there are only limited data identifying the rate of instrumentation changes on radiographs after complex spine surgery involving ≥ 5-level fusions.METHODSThe medical records of 136 adult (≥ 18 years old) patients with spine deformity undergoing elective, primary complex spinal fusion (≥ 5 levels) for deformity correction at a major academic institution between 2010 and 2015 were reviewed. Patient demographics, comorbidities, and intra- and postoperative complication rates were collected for each patient. The authors reviewed the first 5 subsequent postoperative and follow-up radiographs, and determined whether revision of surgery was performed within 5 years postoperatively. The primary outcome investigated in this study was the rate of hardware changes on follow-up radiographs.RESULTSThe majority of patients were female, with a mean age of 53.8 ± 20.0 years and a body mass index of 27.3 ± 6.2 kg/m2 (parametric data are expressed as the mean ± SD). The median number of fusion levels was 9 (interquartile range 7–13), with a mean length of surgery of 327.8 ± 124.7 minutes and an estimated blood loss of 1312.1 ± 1269.2 ml. The mean length of hospital stay was 6.6 ± 3.9 days, with a 30-day readmission rate of 14.0%. Postoperative and follow-up change in stability on radiographs (days from operation) included: image 1 (4.6 ± 9.3 days) 0.0%; image 2 (51.7 ± 49.9 days) 3.0%; image 3 (142.1 ± 179.8 days) 5.6%; image 4 (277.3 ± 272.5 days) 11.3%; and image 5 (463.1 ± 525.9 days) 15.7%. The 3rd year after surgery had the highest rate of hardware revision (5.55%), followed by the 2nd year (4.68%), and the 1st year (4.54%).CONCLUSIONSThis study suggests that the rate of instrumentation changes on radiographs increases over time, with no changes occurring at the first postoperative image. In an era of cost-conscious healthcare, fewer orders for early radiographs after complex spinal fusions (≥ 5 levels) may not impact patient care and can reduce the overall use of healthcare resources.

This is a meta-analysis.Perform a systematic review and quantitative meta-analysis of neurological outcomes from all available spinal epidural abscess (SEA) literature published between 1980 and 2016.Current literature on SEAs lacks large-scale data characterizing prognostic factors and surgical indications.PubMed was queried for studies reporting neurological outcomes from patients undergoing conservative or surgical management for spontaneous SEA. Inclusion criteria included outcomes data measured ≥6 months after presentation, ≥10 human subjects, and diagnosis by magnetic resonance imaging or Computed tomography-myelogram. Where available, demographic data, abscess location, comorbidities, pretreatment neurological deficits, treatment methods, bacterial speciation, and complications were extracted from each study. Potential outcome predictors represented by continuous variables were compared using student t test and categorical variables were compared using the Pearson χ test. Variables identified as potentially associated with outcome (P≤0.05) were subjected to meta-analysis using Cochran-Mantel-Haenszel testing to calculate odds ratios (ORs) and 95% confidence intervals (CIs).In total, 808 patients were analyzed from 20 studies that met inclusion criteria. 456 (56.3%) patients were treated with surgery and antibiotics, and 353 (43.7%) patients were managed with antibiotics alone. Neither surgical intervention (OR=1.01, 95% CI=0.40-2.59), lumbosacral location (OR=1.51, 95% CI=0.23-9.79), nor neurological deficit on presentation (OR=0.88, 95% CI=0.40-1.92) were significantly associated with good (stable or improved) or bad (worsened) neurological outcome, whereas delayed surgery was significantly associated with bad outcome (OR=0.01, 95% CI=0.02-0.62) and cervicothoracic location approached significance for predicting bad outcome (OR=0.41, 95% CI=0.15-1.09).Current literature does not definitively support or oppose surgical intervention in all SEA cases. Therefore, until better evidence exists, the decision to operate must be made on an individual case-by-case basis with the goals of preventing neurological decline, obtaining source control after failed conservative treatment, or restoring spinal stability.

Background Surgical site infection (SSI) may lead to vertebral osteomyelitis, diskitis, paraspinal musculoskeletal infection, and abscess, and remains a significant concern in postoperative management of spinal surgery. SSI is associated with greater postoperative morbidity and increased health care payments. Methods We conducted a retrospective analysis using MarketScan to identify health care utilization payments and risk factors associated with SSI that occurs postoperatively. Known patient- or procedure-related risk factors were searched across those receiving spine surgery who developed postoperative infection. Results A total of 33,061 patients who developed infection after spinal surgery were identified in Marketscan. Overall payments at 6 months, including index hospitalization for those with infection, were $53,573 and $46,985 for the cohort with no infection. At 24 months, the infection group had overall payments of $83,280 and $66,221 for no infection. Risk factors with largest effect size most likely to contribute to infection versus no infection were depression (4.6%), diabetes (3.7), anemia (3.3%), two or more levels (2.8%), tobacco use (2.2%), trauma (2.1%), neoplasm (1.8%), congestive heart failure (1.3%), instrumentation (1.1%), renal failure (0.9%), intravenous drug use (0.8%), and malnutrition (0.5%). Conclusions SSIs were associated with significant health care utilization payments at 24 months of follow-up. The following clinical and procedural risk factors appear to be predictive of postoperative SSI: depression, diabetes, anemia, two or more levels, tobacco use, trauma, neoplasm, congestive heart failure, instrumentation, renal failure, intravenous drug use, and malnutrition. Interpretation of modifiable and nonmodifiable risk factors for infection informs surgeons of expected postoperative course and preoperative risk for this most common and deleterious postoperative complication to spinal surgery.

Background Minimally invasive spine surgery (MISS) has the potential to further advance with the use of robot-assisted (RA) techniques. While RA pedicle screw placement has been extensively investigated, there is a lack of literature on the use of the robot for other tasks, such as accessing Kambin's triangle in percutaneous lumbar interbody fusion (percLIF). Objective To characterize the surgical feasibility and preliminary outcomes of an initial case series of 10 patients receiving percLIF with RA cage placement via Kambin's triangle. Methods We performed a single-center, retrospective review of patients undergoing RA percLIF using robot-guided trajectory to access Kambin's triangle for cage placement. Patients undergoing RA percLIF were eligible for enrollment. Baseline health and demographic information in addition to peri- and postoperative data was collected. The dimensions of each patient's Kambin's triangle were measured. Results Ten patients and 11 levels with spondylolisthesis were retrospectively reviewed. All patients successfully underwent the planned procedure without perioperative complications. Four patients underwent their procedure with awake anesthesia. The average dimension of Kambin's triangle was 66.3 m2. With the exception of 1 patient who stayed in the hospital for 7 d, the average length of stay was 1.2 d, with 2 patients discharged the day of surgery. No patients suffered postoperative motor or sensory deficits. Spinopelvic parameters and anterior and posterior disc heights were improved with surgery. Conclusion As MISS continues to evolve, further exploration of robot-guided surgical practice, such as our technique, will lead to creative solutions to challenging anatomical variation and overall improved patient care.

Primary spine tumors are rare neoplasms that affect about 0.62 per 100,000 individuals in the US. Intramedullary spinal cord tumors (IMSCTs) are the rarest of all primary tumors involving the spine and can cause pain, imbalance, urinary dysfunction and neurological deficits. These types of tumors oftentimes necessitate surgical treatment, yet there is a lack of data on hospital length of stay and complication rates following treatment. Given that treatment candidacy, quality of life, and outcomes are tied so closely to potential for prolonged length of stay and postoperative complications, it is important to better understand the factors that increase the risk of these outcomes in patients with IMSCTs.The National Surgical Quality Improvement Program (NSQIP) database was queried for all patients undergoing surgery for treatment of intramedullary spinal cord tumors between 2005 and 2017. Univariate and multivariate analysis were performed to assess patient risk factors influencing prolonged length of stay and post-op complications.A total of 638 patients were included in the analysis. Pre-operative American Society of Anesthesiology (ASA) physical status classification of 3 and above (OR 1.89; p = 0.0005), dependent functional status (OR 2.76; p = 0.0035) and transfer from facilities other than home (OR 8.12; p 0.0001) were independent predictors of prolonged length of stay (5 days). The most commonly reported complications were pneumonia (5.7%), urinary tract infection (9.4%), septic shock (3.8%), superficial incisional infection (5.7%), organ or space infection (5.7%), pulmonary embolism (11.3%), DVT requiring therapy (15.1%) and wound dehiscence (5.7%).Our study demonstrated the significant influence of clinical variables on prolonged hospitalization of IMSCT patients. This should be factored into clinical and surgical decision making and when counseling patients of their expected outcomes.

OBJECTIVE The use of osteobiologics, engineered materials designed to promote bone healing by enhancing bone growth, is becoming increasingly common for spinal fusion procedures, but the efficacy of some of these products is unclear. The authors performed a retrospective, multi-institutional study to investigate the clinical and radiographic characteristics of patients undergoing single-level anterior cervical discectomy with fusion performed using the osteobiologic agent Osteocel, an allograft mesenchymal stem cell matrix. METHODS The medical records across 3 medical centers and 12 spine surgeons were retrospectively queried for patients undergoing single-level anterior cervical discectomy and fusion (ACDF) with the use of Osteocel. Pseudarthrosis was determined based on CT or radiographic imaging of the cervical spine. Patients were determined to have radiographic pseudarthrosis if they met any of the following criteria: 1) lack of bridging bone on CT obtained > 300 days postoperatively, 2) evidence of instrumentation failure, or 3) motion across the index level as seen on flexion-extension cervical spine radiographs. Univariate and multivariate analyses were then performed to identify independent preoperative or perioperative predictors of pseudarthrosis in this population. RESULTS A total of 326 patients met the inclusion criteria; 43 (13.2%) patients met criteria for pseudarthrosis, of whom 15 (34.9%) underwent revision surgery. There were no significant differences between patients with and those without pseudarthrosis, respectively, for patient age (54.1 vs 53.8 years), sex (34.9% vs 47.4% male), race, prior cervical spine surgery (37.2% vs 33.6%), tobacco abuse (16.3% vs 14.5%), chronic kidney disease (2.3% vs 2.8%), and diabetes (18.6% vs 14.5%) (p > 0.05). Presence of osteopenia or osteoporosis (16.3% vs 3.5%) was associated with pseudarthrosis (p < 0.001). Implant type was also significantly associated with pseudarthrosis, with a 16.4% rate of pseudarthrosis for patients with polyetherethereketone (PEEK) implants versus 8.4% for patients with allograft implants (p = 0.04). Average lengths of follow-up were 27.6 and 23.8 months for patients with and those without pseudarthrosis, respectively. Multivariate analysis demonstrated osteopenia or osteoporosis (OR 4.97, 95% CI 1.51–16.4, p < 0.01) and usage of PEEK implant (OR 2.24, 95% CI 1.04–4.83, p = 0.04) as independent predictors of pseudarthrosis. CONCLUSIONS In patients who underwent single-level ACDF, rates of pseudarthrosis associated with the use of the osteobiologic agent Osteocel are higher than the literature-reported rates associated with the use of alternative osteobiologics. This is especially true when Osteocel is combined with a PEEK implant.

OBJECTIVE The rate of symptomatic adjacent-segment disease (ASD) after newer minimally invasive techniques, such as lateral lumbar interbody fusion (LLIF), is not known. This study aimed to assess the incidence of surgically significant ASD in adult patients who have undergone index LLIF and to identify any predictive factors. METHODS Patients who underwent index LLIF with or without additional posterior pedicle screw fixation between 2010 and 2012 and received a minimum of 2 years of postoperative follow-up were retrospectively included. Demographic and perioperative data were recorded, as well as radiographic data and immediate perioperative complications. The primary endpoint was revision surgery at the level above or below the previous construct, from which a survivorship model of patients with surgically significant symptomatic ASD was created. RESULTS Sixty-seven patients with a total of 163 interbody levels were included in this analysis. In total, 17 (25.4%) patients developed surgically significant ASD and required additional surgery, with a mean ± SD time to revision of 3.59 ± 2.55 years. The mean annual rate of surgically significant ASD was 3.49% over 7.27 years, which was the average follow-up. One-third of patients developed significant disease within 2 years of index surgery, and 1 patient required surgery at the adjacent level within 1 year. Constructs spanning 3 or fewer interbody levels were significantly associated with increased risk of surgically significant ASD; however, instrument termination at the thoracolumbar junction did not increase this risk. Surgically significant ASD was not impacted by preoperative disc height, foraminal area at the adjacent levels, or changes in global or segmental lumbar lordosis. CONCLUSIONS The risk of surgically significant ASD after LLIF was similar to the previously reported rates of other minimally invasive spine procedures. Patients with shorter constructs had higher rates of subsequent ASD.

Study Design: Systematic review and meta-analysis. Objective: To perform a systematic review of clinical outcomes between stand-alone anchored spacers and traditional cages with plate fixation for dysphagia and pseudoarthrosis using data from clinical trials. Methods: Our search protocol was added to PROSPERO register and systematic review using PRISMA method was performed. Then, we systematically searched for studies addressing stand-alone anchored spacers in patients who underwent ACDF. Mean Neck Disability Index (NDI), dysphagia incidence % (Dinc%), and Swallowing–Quality of Life (SQOL) scores during preoperative, immediate postoperative and last follow-up visits were extracted. Chi-square and analysis of variance (ANOVA) tests were used for statistical comparisons ( P ≤ .05). Results: The initial search generated 506 articles in CENTRAL and 40 articles in MEDLINE. Finally, 14 articles were included. Total number of patients was 1173 (583 anchored stand-alone and 590 plate). Dinc% scores were statistically significantly lower in the stand-alone anchored spacer compared to the plate-screw construct ( P ≤ .05). ANOVA showed no statistically significant difference in the comparisons of SQOL. On the other hand, NDI scores were statistically significantly lower in baseline of stand-alone anchored spacer and the plate-screw construct compared with both immediate postoperative and last follow-up visits ( P ≤ .05). Conclusions: Our study results revealed that the stand-alone anchored spacers were associated with less dysphagia in the immediate and last follow-up.

Study Design: Retrospective cohort study. Objective: Recombinant human bone morphogenetic protein–2 (rhBMP-2) is used to achieve fusion in adult spinal deformity (ASD) surgery. Our aim was to investigate the long-term impact of rhBMP-2 use for clinical outcomes and health care utilization in this patient population. Methods: We conducted an analysis using MarketScan to identify health resource utilization of rhBMP-2 use for ASD after surgical intervention compared to fusion without rhBMP-2 at 24 months’ follow-up. Outcomes assessed included length of stay, complications, pseudoarthrosis, reoperation, outpatient services, and health care payments. Results: Of 7115 patients who underwent surgery for ASD, 854 received rhBMP-2 and 6261 were operated upon without use of rhBMP-2. One month after discharge, the rhBMP-2 cohort had a nonsignificant trend in fewer complications (15.38%) than those who did not receive rhBMP-2 (18.07%), P = .0558. At 12 months, pseudoarthrosis was reported in 2.8% of cases with no BMP and 01.14% of cases with BMP, P = .0048. Average payments at 12 months were $120 138 for the rhBMP-2 group and $118 373 for the no rhBMP-2 group, P = .8228. At 24 months, payments were $141 664 for the rhBMP-2 group and $144 179 for the group that did not receive rhBMP-2, P = .5946. Conclusions: In ASD surgery, use of rhBMP-2 was not associated with increased complications or reoperations at index hospitalization and 1-month follow-up. Overall payments, including index hospitalization, readmissions, reoperations, and outpatient services were not different compared to those without the use of rhBMP-2 at 12 months and 24 months after discharge.

Background Intraoperative computed tomography (CT) is becoming more widely utilized in spine fusion surgeries. The use of CT-based image guidance has been shown to increase the accuracy in instrumentation placement and to reduce the rate of reoperation. However, incidental findings that are obvious in retrospect are still missed in spinal fusion surgeries due to the concept of inattentional blindness and surgeons' preoccupation with the main objective of intraoperative CT (i.e. instrumentation accuracy). Case description The first case describes a 60-year-old male who underwent posterior spinal laminectomy and interbody fusions from L2-L5. Intraoperative CT confirmed appropriate placement of hardware. However, when he was transferred out to the care unit and extubated, he developed a severe headache for which the source was confirmed to be a pneumocephalus from durotomy and cerebrospinal fluid leakage on repeat CT. A retrospective review of his intraoperative CT demonstrated the intrathecal air at L5-S1 interlaminar space that was missed on evaluation during surgery. The second case describes a 68-year-old female who was treated with a successful T4 to pelvis instrumentation and fusion with vertebral column resection at T10 confirmed with imaging. Postoperatively, she developed rapidly progressive oxygen desaturation and was found to have a pneumothorax which had been present on the intraoperative imaging. Conclusion This case report of two patients with missed intraoperative findings demonstrates the importance of looking beyond instrumentation placement and evaluating the entire intraoperative CT imaging to find abnormalities that could complicate the patients' postoperative recovery and overall hospital stay.

Spine surgery has been disproportionately impacted by medical liability and malpractice litigation, with the majority of claims and payouts related to procedural error. One common area for the potential avoidance of malpractice claims and subsequent payouts involves misplaced pedicle and/or lateral mass instrumentation. However, the medicolegal impact of misplaced screws on spine surgery has not been directly reported in the literature. The authors of the current study aimed to describe this impact in the United States, as well as to suggest a potential method for mitigating the problem.This retrospective analysis of 68 closed medicolegal cases related to misplaced screws in spine surgery showed that neurosurgeons and orthopedic spine surgeons were equally named as the defendant (n = 32 and 31, respectively), and cases were most commonly due to misplaced lumbar pedicle screws (n = 41, 60.3%). Litigation resulted in average payouts of $1,204,422 ± $753,832 between 1995 and 2019, when adjusted for inflation. The median time to case closure was 56.3 (35.2–67.2) months when ruled in favor of the plaintiff (i.e., patient) compared to 61.5 (51.4–77.2) months for defendant (surgeon) verdicts (p = 0.117).

Background Aneurysms of the anterior spinal artery are extremely rare. Unlike intracranial saccular aneurysms, they do not occur at branch points, are typically pseudoaneurysms, and rupture secondary to a dissection. They typically present with subarachnoid hemorrhage and demonstrate clinical and radiographic improvement over time without treatment. Methods We present here the first case to date of a ruptured anterior spinal artery aneurysm with clinical and radiographic progression treated with Onyx embolization. Our patient was unique in the presentation with acute onset of spinal cord injury American Spinal Injury Association B and an extensive thoracolumbar subdural hematoma. Results An emergent skip-level laminectomy and subdural decompression were performed with no improvement in examination. This was followed by progressive radiographic enlargement of the aneurysm, treated successfully with Onyx embolization. Conclusions We analyze this case and review the literature on thoracic anterior spinal artery and artery of Adamkiewicz aneurysms.

OBJECTIVEIn spine surgery, racial disparities have been shown to impact various aspects of surgical care. Previous studies have associated racial disparities with inferior surgical outcomes, including increased complication and 30-day readmission rates after spine surgery. Recently, patient-reported outcomes (PROs) and satisfaction measures have been proxies for overall quality of care and hospital reimbursements. However, the influence that racial disparities have on short- and long-term PROs and patient satisfaction after spine surgery is relatively unknown. The aim of this study was to investigate the impact of racial disparities on 3- and 12-month PROs and patient satisfaction after elective lumbar spine surgery.METHODSThis study was designed as a retrospective analysis of a prospectively maintained database. The medical records of adult (age ≥ 18 years) patients who had undergone elective lumbar spine surgery for spondylolisthesis (grade 1), disc herniation, or stenosis at a major academic institution were included in this study. Patient demographics, comorbidities, postoperative complications, and 30-day readmission rates were collected. Patients had prospectively collected outcome and satisfaction measures. Patient-reported outcome instruments—Oswestry Disability Index (ODI), visual analog scale for back pain (VAS-BP), and VAS for leg pain (VAS-LP)—were completed before surgery and at 3 and 12 months after surgery, as were patient satisfaction measures.RESULTSThe authors identified 345 medical records for 53 (15.4%) African American (AA) patients and 292 (84.6%) white patients. Baseline patient demographics and comorbidities were similar between the two cohorts, with AA patients having a greater body mass index (33.1 ± 6.6 vs 30.2 ± 6.4 kg/m2, p = 0.005) and a higher prevalence of diabetes (35.9% vs 16.1%, p = 0.0008). Surgical indications, operative variables, and postoperative variables were similar between the cohorts. Baseline and follow-up PRO measures were worse in the AA cohort, with patients having a greater baseline ODI (p < 0.0001), VAS-BP score (p = 0.0002), and VAS-LP score (p = 0.0007). However, mean changes from baseline to 3- and 12-month PROs were similar between the cohorts for all measures except the 3-month VAS-BP score (p = 0.046). Patient-reported satisfaction measures at 3 and 12 months demonstrated a significantly lower proportion of AA patients stating that surgery met their expectations (3 months: 47.2% vs 65.5%, p = 0.01; 12 months: 35.7% vs 62.7%, p = 0.007).CONCLUSIONSThe study data suggest that there is a significant difference in the perception of health, pain, and disability between AA and white patients at baseline and short- and long-term follow-ups, which may influence overall patient satisfaction. Further research is necessary to identify patient-specific factors associated with racial disparities that may be influencing outcomes to adequately measure and assess overall PROs and satisfaction after elective lumbar spine surgery.

The increase in the aging population has led to an overall increase in the number of elderly patients undergoing spinal fusion surgery. This patient population, however, exhibits significant treatment challenges because of poor bone quality. By virtue of exhibiting decreased pullout strength and insertional torque, osteoporotic patients are at a substantial risk of developing vertebral fractures, instrumentation failure, pseudoarthrosis, and proximal junctional failures. It is, therefore, imperative for the treating surgeon to optimize bone health before recommending a spinal fusion surgery. Several preoperative medical therapies (vitamin D, calcium, bisphosphonates, parathyroid hormone, and so forth) exist to optimize bone health.

Measures of health care use such as length of hospital stay (LOS) are used as proxies for quality of care after spine surgery. Accordingly, hospitals and health systems are investing considerable resources into the preoperative identification of patients at risk for prolonged LOS. This study aims to investigate the impact of preoperative level on outcomes and LOS after spinal fusion.The medical records of 204 elderly (≥60 years) male patients undergoing elective spinal fusion (≥3 levels) at a major academic institution from 2005 to 2015 were reviewed. The lower hemoglobin (Hgb) level was designated as13.5 g/dL. We identified 83 (40.7%) patients with preoperative lower Hgb levels and 121 (59.3%) with normal levels (low Hgb, n = 83; normal Hgb, n = 121). The primary outcomes investigated were complications and LOS.Demographics and comorbidities were similar between both groups, with mean Hgb levels being 12.3 ± 0.9 g/dL and 14.9 ± 1.0 g/dL for the low and normal cohorts, respectively. The lower Hgb cohort experienced higher rates of postoperative delirium (21.7% vs. 5.8%; P = 0.0007), non-wound infections (6.0% vs. 0.0%; P = 0.006), and hematoma formation (3.6% vs. 0.0%; P = 0.035). There was a significant difference in LOS between the cohorts, with the low Hgb cohort experiencing approximately a 2-fold increase (low Hgb, 8.1 ± 5.9 days vs. normal Hgb, 4.8 ± 2.5 days; P0.0001). Preoperative Hgb and hematocrit levels negatively correlated with LOS (Hgb, R = -0.388, P0.001 and Hct, R = -0.2883, P0.001).Our study shows that elderly male patients with lower preoperative Hgb levels have increased LOS and postoperative delirium after spinal fusion. Moreover, preoperative Hgb levels negatively correlate with LOS.

Management of spine fractures among the elderly is complicated by preexisting comorbidities and increased risk of osseous nonunion. Whether operative treatment is superior for the management of thoracolumbar fractures in the aged is unknown. The purpose of this study was to investigate the rates of in-hospital medical complications after non-operative and operative treatment of thoracolumbar fractures in elderly patients. The Nationwide Inpatient Sample database from 2002 to 2011 was used to identify patients over 75 years of age with a principal discharge diagnosis of thoracolumbar fracture without spinal cord injury. Three treatment groups were compared: non-operative treatment, operative treatment, and minimally-invasive vertebroplasty/kyphoplasty (VP/KP). A total of 59,565 patients were identified; 46,962 treated non-operatively, 1,487 treated operatively, and 11,116 treated with VP/KP. Operative patients had the longest length of hospital stay (P 0.001) and the highest injury severity scores (P 0.001). The percentage of patients who developed at least one complication was highest in the operative group (16.3%), versus 8.7% in the non-operative and 8.1% in the VP/KP group (P 0.001). Even after controlling for potential confounders such as injury severity score, surgical patients had significantly higher odds of complication occurrence (P 0.001). Adjusted charges were highest for operative patients ($123,777 ± 135,997 vs. $27,116 ± 32,694 [non-operative] and $42,326 ± 31,984 [VP/KP]). Operative treatment for elderly patients has higher complication rates that need to be considered during preoperative patient counseling. Future research is necessary to elucidate the comparative rates of long-term complications and functional status outcomes for thoracolumbar fracture treatment among elderly patients.

Interdisciplinary management of elderly patients requiring spine surgery has been shown to improve short- and long-term outcomes. The aim of this study was to determine whether an interdisciplinary team approach mitigates use of intensive care unit (ICU) resources.A unique comanagement model for elderly patients undergoing lumbar fusion surgery was implemented at a major academic medical center. The Peri-operative Optimization of Senior Health Program (POSH) was launched with the aim of improving outcomes in elderly patients (65 years old) undergoing complex lumbar spine surgery. In this model, a geriatrician evaluates elderly patients preoperatively, comanages daily throughout hospital course, and coordinates multidisciplinary rehabilitation, along with the neurosurgical team. We retrospectively reviewed the first 100 cases after the initiation of the POSH protocol and compared them with the immediately preceding 25 cases to assess the rates of ICU transfer and independent predictors of ICU admission.A total of 125 patients undergoing lumbar decompression and fusion surgery were enrolled in this pilot program. Baseline characteristics and intraoperative variables, as well as number of fusion levels and duration of surgery, were similar between both cohorts. There was a significant difference in the use of ICU services (ICU admission rates) between both cohorts, with the non-POSH cohort having a 3-fold increase compared with the POSH cohort (P0.0001). In a multivariate analysis, lack of an interdisciplinary comanagement team approach was an independent predictor for ICU transfers in elderly patients undergoing corrective surgery (odds ratio 8.51, 95% confidence interval 2.972-24.37, P0.0001).Our study suggests that an interdisciplinary comanagement model between geriatrics and neurosurgery is independently associated with reduced use of critical care services.

OBJECTIVEPostoperative delirium is common in elderly patients undergoing spine surgery and is associated with a longer and more costly hospital course, functional decline, postoperative institutionalization, and higher likelihood of death within 6 months of discharge. Preoperative cognitive impairment may be a risk factor for the development of postoperative delirium. The aim of this study was to investigate the relationship between baseline cognitive impairment and postoperative delirium in geriatric patients undergoing surgery for degenerative scoliosis.METHODSElderly patients 65 years and older undergoing a planned elective spinal surgery for correction of adult degenerative scoliosis were enrolled in this study. Preoperative cognition was assessed using the validated Saint Louis University Mental Status (SLUMS) examination. SLUMS comprises 11 questions, with a maximum score of 30 points. Mild cognitive impairment was defined as a SLUMS score between 21 and 26 points, while severe cognitive impairment was defined as a SLUMS score of ≤ 20 points. Normal cognition was defined as a SLUMS score of ≥ 27 points. Delirium was assessed daily using the Confusion Assessment Method (CAM) and rated as absent or present on the basis of CAM. The incidence of delirium was compared in patients with and without baseline cognitive impairment.RESULTSTwenty-two patients (18%) developed delirium postoperatively. Baseline demographics, including age, sex, comorbidities, and perioperative variables, were similar in patients with and without delirium. The length of in-hospital stay (mean 5.33 days vs 5.48 days) and 30-day hospital readmission rates (12.28% vs 12%) were similar between patients with and without delirium, respectively. Patients with preoperative cognitive impairment (i.e., a lower SLUMS score) had a higher incidence of postoperative delirium. One- and 2-year patient reported outcomes scores were similar in patients with and without delirium.CONCLUSIONSCognitive impairment is a risk factor for the development of postoperative delirium. Postoperative delirium may be associated with decreased preoperative cognitive reserve. Cognitive impairment assessments should be considered in the preoperative evaluations of elderly patients prior to surgery.

Background: To investigate the inpatient perioperative morbidity rate of patients with movement disorders (MD) after spinal deformity surgery. Methods: The Nationwide Inpatient Sample database from 2002 to 2011 was queried to identify adult patients with MD who underwent spinal deformity surgery. Complication rates were compared between patients with MD and controls. A multiple logistic regression analysis was conducted to assess the effect of MD on outcome. Results: A total of 365 patients with MD (3.3%) were identified among 11,043 patients undergoing surgery for spinal deformity. Patients with MD were on average 8 years older than the control group (67 vs . 59 years of age, P Conclusions: Patients with MD who undergo spinal deformity surgery may be at risk of higher rate of complications compared to patients without these disorders.

OBJECTIVEGeriatric patients undergoing lumbar spine surgery have unique needs due to the physiological changes of aging. They are at risk for adverse outcomes such as delirium, infection, and iatrogenic complications, and these complications, in turn, contribute to the risk of functional decline, nursing home admission, and death. Whether preoperative and perioperative comanagement by a geriatrician reduces the incidence of in-hospital complications and length of in-hospital stay after elective lumbar spine surgery remains unknown.METHODSA unique model of comanagement for elderly patients undergoing lumbar fusion surgery was implemented at a major academic medical center. The Perioperative Optimization of Senior Health (POSH) program was launched with the aim of improving outcomes in elderly patients (> 65 years old) undergoing complex lumbar spine surgery. In this model, a geriatrician evaluates elderly patients preoperatively, in addition to performing routine preoperative anesthesia surgical screening, and comanages them daily throughout the course of their hospital stay to manage medical comorbid conditions and coordinate multidisciplinary rehabilitation along with the neurosurgical team. The first 100 cases were retrospectively reviewed after initiation of the POSH protocol and compared with the immediately preceding 25 cases to assess the incidence of perioperative complications and clinical outcomes.RESULTSOne hundred twenty-five patients undergoing lumbar decompression and fusion were enrolled in this pilot program. Baseline characteristics were similar between both cohorts. The mean length of in-hospital stay was 30% shorter in the POSH cohort (6.13 vs 8.72 days; p = 0.06). The mean duration of time between surgery and patient mobilization was significantly shorter in the POSH cohort compared with the non-POSH cohort (1.57 days vs 2.77 days; p = 0.02), and the number of steps ambulated on day of discharge was 2-fold higher in the POSH cohort (p = 0.04). Compared with the non-POSH cohort, the majority of patients in the POSH cohort were discharged to home (24% vs 54%; p = 0.01).CONCLUSIONSGeriatric comanagement reduces the incidence of postoperative complications, shortens the duration of in-hospital stay, and contributes to improved perioperative functional status in elderly patients undergoing elective spinal surgery for the correction of adult degenerative scoliosis.

Hospital readmission after surgery results in a substantial economic burden, and several recent studies have investigated the impact of race and ethnicity on hospital readmission rates, with the goal to identify hospitals and patients with high readmission risk. This single-institution, retrospective cohort study assesses the impact of race, along with other risk factors, on 30-day readmission rates following spinal surgery. This study is a single-institution retrospective cohort study with accrual from January 1, 2008, to December 31, 2010. Inclusion criteria included adult patients who underwent anterior and/or posterior spinal surgery. The primary aim of this study was to assess the impact of patient race and other risk factors for postoperative hospital readmission within 30 days following spine surgery. A total of 1346 patients (654 male, 692 female) were included in the study. Overall, 159 patients (11.8%) were readmitted in the 30 days following their surgery. Multivariate logistic regression found significant risk factors for 30-day readmission, including Black race (OR: 2.20, C.I. 95% (1.04, 4.64)) and total length of stay greater than 7 days (OR: 4.73, C.I. 95% (1.72, 12.98)). Cervical surgery was associated with decreased odds of readmission (OR: 0.27, C.I. 95% (0.08, 0.91)). Our study demonstrates that race and length of hospital stay influence the incidence of 30-day readmission rates after spinal surgery. Studies such as ours will aid in identifying patients with postoperative readmission risk and help elucidate the underlying factors that may be contributing to disparities in readmission after surgery.

Background There is a paucity of data determining the impact that gender disparities have on spine outcomes, particularly perception of health and satisfaction. The aim of this study was to determine whether there is a difference in 3-month and 1-year patient-reported outcomes and satisfaction after elective lumbar spine surgery. Methods This was a retrospectively analyzed study from a maintained prospective database of 384 patients who underwent elective lumbar spine surgery. Patients were categorized by gender (men, n = 199; women, n = 185). Patient-reported outcome instruments (Oswestry disability index, visual analogue scale-back pain/leg pain, EuroQol visual analogue scale, and EuroQol 5 dimensions questionnaire) were completed before surgery, then at 3 and 12 months after surgery along with patient satisfaction measures. Results Baseline patient demographics, comorbidities, and operative variables were similar between both cohorts. The female cohort had a slightly longer hospital stay than male cohort (P = 0.007). Baseline patient-reported outcome measures were different between both cohorts, with female patients having more Oswestry disability index (23.8 vs. 20.4; P ≤ 0.0001) and visual analogue scale-back pain (7.2 vs. 6.2; P = 0.0004), and a lower EuroQol 5 dimensions questionnaire (0.34 vs. 0.49; P = 0.0001) compared with the male cohort. At 1-year follow-up, the male cohort had a significantly more mean change in visual analogue scale-leg pain (−3.9 vs. −2.8; P = 0.04) and trended to have more mean change in visual analogue scale-back pain (−3.4 vs. −2.5; P = 0.06) and EuroQol visual analogue scale (8.6 vs. 3.4; P = 0.054) scores compared with the female cohort. At 1-year a significantly more portion in the male cohort found that surgery met their expectations compared with the female cohort (65.0% vs. 49.5%; P = 0.02). Conclusions Our study suggests that there may be differences in perception of health, pain, and disability between men and women at baseline, short-term and long-term follow-up that may influence overall patient satisfaction.

Background The aim of this study was to assess whether the Koenig Depression Scale (KDS) can identify depressed elderly patients undergoing elective spine surgery for deformity at risk for inferior postoperative outcomes including complication rates, ambulation ability, and patient-reported outcomes. Methods The medical records of 92 elderly patients (≥65 years) undergoing a planned elective spinal surgery for correction of adult degenerative scoliosis were reviewed for this study. Preoperative baseline depression was assessed using the validated KDS that was administered by a board-certified geriatrician. KDS is made up of 11 questions with a maximum of 11 points (No-Depression = KDS Results Of the 92 patients, 20 of them (21.7%) were found to have a KDS ≥4. Baseline demographics and comorbidities were similar between both cohorts. Intraoperative variables and complications were similar between both cohorts. There were no significant differences in postoperative complications including length of hospital stay. There was no significant difference in ambulation abilities including preoperative gait speed (P = 0.38), days from operation to ambulation (P = 0.86), steps on first day of ambulation (P = 0.57), and steps before hospital discharge (P = 0.35). There was no significant difference between the cohorts in VAS scores at baseline (P = 0.19), 6 weeks (P = 0.91), 3 months (P = 0.58), and 6 months (P = 0.97) after hospital discharge. Conclusions Our study found no difference in complication rates, ambulation abilities, and follow-up VAS scores between patients with and without depression using preoperative KDS.

Study Design: Retrospective cohort study. Objectives: To analyze the impact of performing a formal decompression in patients with adult lumbar scoliosis with symptomatic spinal stenosis on perioperative complications and long-term outcomes. Methods: Adult patients undergoing at least 5 levels of fusion to the sacrum with iliac fixation from 2002 to 2008 who had a minimum 5-year follow-up at one institution were studied. Patients who had 3-column osteotomy were excluded from the study. Perioperative complications and clinical outcomes (Scoliosis Research Society [SRS], Oswestry Disability Index [ODI], and Numerical Rating Scale [NRS] back/leg pain) were analyzed. Patients who underwent formal laminectomy/decompressions were compared with those who did not. Differences between the 2 groups were analyzed using Student’s t test. Results: A total of 147 patients were included in the study (Decompression: n = 55 [37%], No decompression: n = 92 [63%]). Average fusion levels for the decompression and no decompression groups were 11 and 12 levels, respectively ( P = .26). Mean improvements in SRS domains for decompression versus no decompression patients, respectively, were pain (1.1 vs 0.9, P = .3), function (0.7 vs 0.5, P = .09), self-image (1.1 vs 1.1, P = .9), and mental health (0.5 vs 0.4, P = .5). Furthermore, additional mean improvements were ODI (21 vs 21, P = .14), NRS-Back pain (3.0 vs 1.3, P = .16), and NRS-Leg pain (3.9 vs 0.5, P = .002). Complication rates between the decompression group and no decompression group differed in incidental durotomies (18.2% vs 0%) and cardiac-related (9.1% vs 1.1%). Conclusions: Performing a formal decompression in adult lumbar scoliosis with symptomatic spinal stenosis is associated with increased perioperative complications but favorable long-term clinical outcomes.

OBJECTIVEWound infections following spinal surgery for deformity place a high toll on patients, providers, and the health care system. The prophylactic application of intraoperative vancomycin powder has been shown to lower the infection risk after thoracolumbar decompression and fusion for deformity correction. The purpose of this study was to assess the microbiological patterns of postoperative surgical site infections (SSIs) after prophylactic use of vancomycin powder in adult patients undergoing spinal deformity surgery.METHODSAll cases involving adult patients who underwent spinal deformity reconstruction at Duke University Medical Center between 2011 and 2013 with a minimum of 3 months of clinical follow-up were retrospectively reviewed. In all cases included in the study, crystalline vancomycin powder was applied to the surgical bed for infection prophylaxis. Baseline characteristics, operative details, rates of wound infection, and microbiological data for each case were gathered by direct medical record review.RESULTSA total of 1200 consecutive spine operations were performed for deformity between 2011 and 2013. Review of the associated records demonstrated 34 cases of SSI, yielding an SSI rate of 2.83%. The patients’ mean age (± SD) was 62.08 ± 14.76 years. The patients’ mean body mass index was 30.86 ± 7.15 kg/m2, and 29.41% had a history of diabetes. The average dose of vancomycin powder was 1.41 ± 2.77 g (range 1–7 g). Subfascial drains were placed in 88% of patients. All SSIs occurred within 30 days of surgery, with deep wound infections accounting for 50%. In 74% of the SSIs cultures were positive, with about half the organisms being gram negative, such as Citrobacter freundii, Proteus mirabilis, Morganella morgani, and Pseudomonas aeruginosa. There were no adverse clinical outcomes related to the local application of vancomycin.CONCLUSIONSOur study suggests that in the setting of prophylactic vancomycin powder use, the preponderance of SSIs are caused by gram-negative organisms or are polymicrobial. Further randomized control trials of prophylactic adjunctive measures are warranted to help guide the choice of empirical antibiotic therapy while awaiting culture data.

OBJECTIVEDepression is the most prevalent affective disorder in the US, and patients with spinal deformity are at increased risk. Postoperative delirium has been associated with inferior surgical outcomes, including morbidity and mortality. The relationship between depression and postoperative delirium in patients undergoing spine surgery is relatively unknown. The aim of this study was to determine if depression is an independent risk factor for the development of postoperative delirium in patients undergoing decompression and fusion for deformity.METHODSThe medical records of 923 adult patients (age ≥ 18 years) undergoing elective spine surgery at a single major academic institution from 2005 through 2015 were reviewed. Of these patients, 255 (27.6%) patients had been diagnosed with depression by a board-certified psychiatrist and constituted the Depression group; the remaining 668 patients constituted the No-Depression group. Patient demographics, comorbidities, and intra- and postoperative complication rates were collected for each patient and compared between groups. The primary outcome investigated in this study was rate of postoperative delirium, according to DSM-V criteria, during initial hospital stay after surgery. The association between depression and postoperative delirium rate was assessed via multivariate logistic regression analysis.RESULTSPatient demographics and comorbidities other than depression were similar in the 2 groups. In the Depression group, 85.1% of the patients were taking an antidepressant prior to surgery. There were no significant between-group differences in intraoperative variables and rates of complications other than delirium. Postoperative complication rates were also similar between the cohorts, including rates of urinary tract infection, fever, deep and superficial surgical site infection, pulmonary embolism, deep vein thrombosis, urinary retention, and proportion of patients transferred to the intensive care unit. In total, 66 patients (7.15%) had an episode of postoperative delirium, with depressed patients experiencing approximately a 2-fold higher rate of delirium (10.59% vs 5.84%). In a multivariate logistic regression analysis, depression was an independent predictor of postoperative delirium after spine surgery in spinal deformity patients (p = 0.01).CONCLUSIONSThe results of this study suggest that depression is an independent risk factor for postoperative delirium after elective spine surgery. Further studies are necessary to understand the effects of affective disorders on postoperative delirium, in hopes to better identify patients at risk.

In the last decade, costs of U.S. healthcare expenditures have been soaring, with billions of dollars spent on hospital readmissions. Identifying causes and risk factors can reduce soaring readmission rates and help lower healthcare costs. The aim of this is to determine if post-operative delirium in the elderly is an independent risk factor for 30-day hospital readmission after spine surgery. The medical records of 453 consecutive elderly (≥65years old) patients undergoing spine surgery at Duke University Medical Center from 2008 to 2010 were reviewed. We identified 17 (3.75%) patients who experienced post-operative delirium according to DSM-V criteria. Patient demographics, comorbidities, and post-operative complication rates were collected for each patient. Elderly patients experiencing post-operative delirium had an increased length of hospital stay (10.47days vs. 5.70days, p=0.009). Complication rates were similar between the cohorts with the post-operative delirium patients having increased UTI and superficial surgical site infections. In total, 12.14% of patients were re-admitted within 30-days of discharge, with post-operative delirium patients experiencing approximately a 4-fold increase in 30-day readmission rates (Delirium: 41.18% vs. No Delirium: 11.01%, p=0.002). In a multivariate logistic regression analysis, post-operative delirium is an independent predictor of 30-day readmission after spine surgery in the elderly (p=0.03). Elderly patients experiencing post-operative delirium after spine surgery is an independent risk factor for unplanned readmission within 30-days of discharge. Preventable measures and early awareness of post-operative delirium in the elderly may help reduce readmission rates.

Recent studies have reported that decompression with fusion leads to superior outcomes in correction of spinal deformity. The aim of this study was to determine if there is a difference in intraoperative and 30-day postoperative complication rates in patients undergoing spinal fusion with and without decompression.Medical records of 874 adult (≥18 years old) patients with spinal deformity undergoing elective spinal fusion at a major academic institution from 2005 to 2015 were reviewed; 374 (42.8%) patients underwent laminectomy in addition to spinal fusion. The primary outcome investigated was the rate of intraoperative and 30-day complications.Patient demographics and comorbidities were similar between groups. The laminectomy cohort had significantly higher estimated blood loss (P0.0001), incidence of allogeneic blood transfusions (P = 0.0001), and rate of intraoperative durotomies (laminectomy cohort 10.4% vs. no-laminectomy cohort 3.1%; P0.0001). The laminectomy cohort had a significantly higher proportion of patients in the intensive care unit (28.6% vs. 17.7%; P 0.001). There was no significant difference in 30-day readmission rate between cohorts (laminectomy cohort 13.0% vs. no-laminectomy cohort 9.8%; P = 0.13). Within 30 days after initial discharge, the laminectomy cohort had significantly higher rates of altered mental status (3.2% vs. 1.2%; P = 0.05), urinary tract infection (4.3% vs. 1.4%; P = 0.009), wound drainage (7.2% vs. 3.1%; P = 0.007), and instrumentation failure (1.1% vs. 0.0%; P = 0.03).Patients undergoing spinal fusion with laminectomy may have higher complication rates than patients undergoing spinal fusion alone.

Study Design: Retrospective cohort review. Objective: To assess whether immediate postoperative neck pain scores accurately predict 12-month visual analog scale–neck pain (VAS-NP) outcomes following Anterior Cervical Discectomy and Fusion surgery (ACDF). Methods: This was a retrospective study of 82 patients undergoing elective ACDF surgery at a major academic medical center. Patient reported outcomes measures VAS-NP scores were recorded on the first postoperative day, then at 6-weeks, 3, 6, and 12-months after surgery. Multivariate correlation and logistic regression methods were utilized to determine whether immediate postoperative VAS-NP score accurately predicted 1-year patient reported VAS-NP Scores. Results: Overall, 46.3% male, 25.6% were smokers, and the mean age and body mass index (BMI) were 53.7 years and 28.28 kg/m2, respectively. There were significant correlations between immediate postoperative pain scores and neck pain scores at 6 weeks VAS-NP ( P = .0015), 6 months VAS-NP ( P = .0333), and 12 months VAS-NP ( P = .0247) after surgery. Furthermore, immediate postoperative pain score is an independent predictor of 6 weeks, 6 months, and 1 year VAS-NP scores. Conclusion: Our study suggests that immediate postoperative patient reported neck pain scores accurately predicts and correlates with 12-month VAS-NP scores after an ACDF procedure. Patients with high neck pain scores after surgery are more likely to report persistent neck pain 12 months after index surgery.

Background Altered mental status (AMS) has been associated with inferior surgical outcomes. The factors leading to AMS after spine surgery are unknown. The aim of this study is to determine the risk factors and independent predictors of 30-day readmission for AMS in patients with spine deformity after undergoing elective spine surgery. Methods The medical records of 1090 adult (≥18 years old) patients with spine deformity undergoing elective spine surgery at a major academic institution from 2005 to 2015 were reviewed. We identified 18 patients (1.65%) who had AMS as the primary driver for 30-day readmission after surgery. Patient demographics, comorbidities, and intraoperative and postoperative complication rates were collected for each patient. The primary outcome investigated in this study was risk factors associated with 30-day readmission for AMS. Results Patient demographics and comorbidities were similar between both groups, with the AMS cohort being significantly older than the no-AMS cohort (70.11 vs. 61.93; P = 0.003). There were no significant differences in intraoperative variables and complication rates within the cohorts. The AMS cohort had a significantly higher proportion of patients transferred to the intensive care unit (AMS, 61.11% vs. no-AMS, 19.76%; P = 0.0002) and rate of pulmonary embolism (AMS, 11.11 vs. no-AMS, 0.93; P = 0.02) after surgery. Other postoperative complication rates were similar between the cohorts. In a multivariate stepwise regression analysis, age (P = 0.013) and ICU transfer (P = 0.0002) were independent predictors of 30-day readmission for AMS. Conclusions Our study suggests that increasing age and intensice care unit transfer are independent predictors of 30-day readmission for AMS after spine surgery in patients with spine deformity.

The aim of this study is to determine if there are differences in 30-day postoperative complication and readmission rates between patients with spinal deformity undergoing complex spinal fusion with and without intraoperative monitoring (IOM).The medical records of 643 adult patients with spine deformity undergoing elective complex spinal fusion (≥4 levels) at a major academic institution from 2005 to 2015 were reviewed. We identified 122 cases (19%) that involved IOM including electromyography, somatosensory evoked potential, and/or transcranial motor evoked potential and 521 (81%) that did not (IOM, n = 122; no-IOM, n = 521). The primary outcome investigated was the rate of 30-day postoperative complications and readmission.Patient demographics and comorbidities were similar between both groups, including age, gender, body mass index, and smoking status. IOM cases had significantly increased operative time (IOM, 360.9 ± 153.8 minutes vs. no-IOM, 290.3 ± 127.1 minutes; P0.0001), with no differences in the incidences of spinal cord injury, nerve injury, and durotomy. Both cohorts had similar postoperative complications and length of hospital stay, with the no-IOM cohort having a greater incidence of intensive care unit transfer (no-IOM, 27.1% vs. IOM, 16.1%, P = 0.015). There was no significant difference in 30-day readmission between the cohorts (IOM, 8.2% vs. no-IOM, 12.3%; P = 0.27) or differences in sensorimotor deficits. Although the overall 30-day complication rate trended to be higher in the no-IOM cohort, these factors were not attributed to IOM use.Our study suggests that the use of IOM may not have a significant impact on overall surgical outcomes and 30-day readmission rates.

Study design Ambispective cohort review. Objective The aim of this study was to determine the effect of allogeneic red blood cell (RBC) transfusion on postoperative patient complications profiles and 30-day readmission rates following elective spine surgery. Summary of background data Thirty-day hospital readmission rates are being used as a proxy for quality of care. Intra- or perioperative allogeneic RBC transfusions are associated with deleterious effects. Whether allogeneic RBC transfusions are associated with higher perioperative complications and 30-day readmission rates after elective spine surgery remains unknown. Methods The medical records of 160 patients undergoing elective spine surgery at a major academic medical center were reviewed. Patient demographics, comorbidities, and postoperative complication rates were collected. All patients completed patient-reported outcomes instruments (Oswestry Disability Index, SF-36, and VAS-NP/BP/LP) before surgery, then at 3, 6, and 12 months after surgery. The association between intra- or perioperative allogeneic RBC transfusions and 30-day readmission rate was assessed via multivariate logistic regression analysis. Results Baseline characteristics were similar in both cohorts. The mean pre- and postoperative hemoglobin levels were lower for the transfusion than nontransfusion cohorts. Postoperative complication rates were 44.67% and 23.00% in the transfusion and nontransfusion cohorts, respectively. Overall, 9.38% of patients were re-admitted within 30 days of hospital discharge, with a three-fold higher increase in 30-day readmission rate in the transfusion cohort compared to the nontransfusion cohort (no transfusion: 5% vs. transfusion: 16.67%, P = 0.01). In a multivariate logistic regression model, intra- or perioperative allogeneic RBC transfusion was an independent predictor of 30-day readmission after elective spine surgery (P = 0.005). Conclusion Our study suggests that allogeneic RBC transfusions may be associated with increased postoperative complications, length of hospital stay, and 30-day readmission rates. Level of evidence 3.

Study design Retrospective cohort review. Objective To identify the rates, causes, and risk factors for 30-day unplanned readmissions in after elective spine surgery at our institution. Summary of background data Early readmission after spine surgery is being used as a proxy for quality of care. One-fifth of patients are rehospitalized within 30 days after spine surgery. Nearly 60% of these readmissions are unplanned, which translates into billions of dollars in healthcare costs. Methods A total of 1400 patients undergoing elective spine surgery at Duke University Hospital between 2008 and 2010 were included in the study. We identified all unplanned readmissions within 30 days of discharge. Unplanned readmissions were defined to have occurred as a result of either a surgical or a nonsurgical complication. Patient records were reviewed to determine the cause of readmission and the length of hospital stay. Results A total of 132 (9.4%) unplanned early readmissions were identified. The mean ± SD age was 58.6 ± 15.1 years. Lumbar decompression and fusion was the most common procedure The most common causes for readmission were infection or a concern for infection (34.8%) and pain (19.7%), and 26.5% of readmissions required a return to the operating room. The majority of patients that were readmitted presented to the emergency department from home (58.0%) whereas 25.2% were readmitted from a skilled nursing facility. The mean ± SD number of days from discharge to readmission was 9.8 ± 7.9 days and the average length of hospital stay for the readmissions was 7.5 days. Conclusion This study suggests that infection and refractory pain were the most common primary reasons for unplanned readmission. Efforts at reducing unplanned early readmission after elective spine surgery should be focused on more effective post discharge care.

Objective Racial disparities have been shown to affect surgical outcomes. However, the effect of race on complex spinal fusion outcomes remains understudied. The aim of this study is to determine if patient race affects 30-day complication rates after elective complex spinal fusion (≥5 levels). Methods The medical records of 490 adult patients with spinal deformity undergoing elective complex spinal fusion (≥5 levels) at a major academic institution from 2005 to 2015 were reviewed. We identified 52 black patients (11.7%) and 438 white patients (88.3%). Patient demographics, comorbidities, and intraoperative and 30-day postoperative complication and readmission rates were collected. The primary outcome investigated in this study was the rate of 30-day postoperative complications. Results Patient demographics and comorbidities were similar between both groups, including age, gender, and body mass index. Median (interquartile range) number of fusion levels and operative time were similar between the cohorts (black, 6.5 [5–9] vs. white, 7 [5–9]; P = 0.55; and black, 307.3 ± 120.2 minutes vs. white, 321.3 ± 135.3 minutes; P = 0.45, respectively). Both cohorts had similar postoperative complications and lengths of hospital stay (black, 7.2 ± 5.4 days vs. white: 6.5 ± 4.9; P = 0.37). There was no significant difference in 30-day readmission between the cohorts (black, 9.6% vs. white, 12.8%; P = 0.66). There were no observed differences in 30-day complication rates, including: pain ( P = 0.74), urinary tract infection ( P = 0.68), hardware failure ( P = 0.36), wound dehiscence ( P = 0.29), and drainage ( P = 0.86). Conclusions Our study suggests that there is no difference between races in 30-day complication and readmission rates after complex spinal surgery requiring ≥5 levels of fusion.

Background: Growing scrutiny has placed hospitals at the center of readmission prevention. The relationship between pre-operative employment status, length of hospital stays (LOS) and 30-day readmission rates after elective spine surgery remains unclear. Methods: The medical records of 360 patients (employed: n=174, unemployed: n=70, retired: n=40, disabled: n=76) undergoing elective spine surgery at a major academic medical center were reviewed. Patient demographics, comorbidities, and post-operative complication rates were recorded. All patients had comprehensive 1-year patient reported outcomes (PROs) measures. We hypothesized that employment status is associated with decreased LOS and decreased risk of 30-day readmission after elective spine surgery. All-cause readmissions within 30 days of discharge was the primary outcome variable. Results: Baseline characteristics were similar in all cohorts. There was no difference in operative time, estimated blood loss (EBL), or number of fusion levels between all patient cohorts. There were no significant differences in peri-operative complication rates between patient cohorts. On average, the LOS was shorter for the employed compared to non-employed patients (4.89 vs . 5.26 days). The rate of 30-day readmission was 2-fold greater unemployed compared to employed patients (5.17% vs . 10%). At 1-year after surgery, employed patients were more likely to express functional improvement (change in ODI score) compared to unemployed patients (ODI: employed: 33.80 vs . unemployed: 41.93). Conclusions: Our study suggests that employment status may be associated with shorter duration of hospital stay, lower 30-day readmission rates and greater functional improvement. Future interventions to reduce unplanned hospital readmissions should consider pre-operative employment status.

STUDY DESIGN Randomized controlled trial. OBJECTIVE To compare radiation exposure between ultra-low radiation imaging (ULRI) with image enhancement and standard-dose fluoroscopy for patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA Although the benefits of MIS are lauded by many, there is a significant amount of radiation exposure to surgeon and operating room personnel. Our goal with this work was to see if by using ultra-low dose radiation settings coupled with image enhancement, this exposure could be minimized. METHODS An institutional review board approved, prospective, internally randomized controlled trial was performed comparing ultra-low dose settings coupled with image enhancement software to conventional fluoroscopic imaging. In this study, each patient served as their own control, randomly assigning one side of MIS-TLIF for cannulation and K-wire placement using each imaging modality. Further, the case was also randomly divided into screw placement and cage placement/final images to allow further comparisons amongst patients. Radiation production from the C-arm fluoroscope and radiation exposure to all operating room personnel were recorded. RESULTS Twenty-four patients were randomly assigned to undergo a single level MIS-TLIF. In no case was low radiation imaging abandoned, and no patient had a neurologic decline or required hardware repositioning. Everyone in the operating room-the physician, scrub nurse, circulator, and anesthesiologist-all benefited with 61.6% to 83.5% reduction in radiation exposure during cannulation and K-wire placement to screw insertion aided by ULRI. In every case but the anesthesiologist dose, this was statistically significant (P

BACKGROUND CONTEXT Instrument-navigation modalities including CT-guided and robot-assisted methods claim both efficacy and accuracy when applied to spine surgery, yet often increase setup and operating times. PURPOSE The authors seek to study the impact of multitude of instrument navigational technologies on operative time and the learning curve associated with their use. STUDY DESIGN/SETTING Prospective, single-surgeon, single-institution. PATIENT SAMPLE Patients undergoing minimally invasive transforaminal lumbar interbody fusion with or without decompression, with or without previous hardware removal. OUTCOME MEASURES Total operative time, immediate surgical complications. METHODS Consecutive patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) were analyzed. Two adjunctive technologies were studied and compared with a more conventional fluoroscopic approach without navigation. Consecutive cases were done with assistance of a robot (Mazor Robotics), with the assistance of x-ray tracking (TrackX) or without navigation in three consecutive blocks of time. The cases done without assistance were used to further normalize for number of interbodies and decompressions performed as well as hardware removal if needed. Age, body mass index (BMI), sex, operative levels, laminectomy, need for hardware removal, and total operative time was recorded directly from EPIC. RESULTS A total of 120 cases (74 conventional, 14 robot-assisted, 32 Track-X) were included in analysis. There were no significant differences in age, sex, or BMI between modalities. Uncontrolled, the average operative time for conventional, robot-assisted, and TrackX was 118±36, 157±41, and 107±37 minutes, respectively, for each MIS-TLIF level (p CONCLUSIONS Enabling technology can have a significant impact to surgical efficiency. Robotic-assistance consistently negatively impacted operative times, while x-ray tracking was associated with a short learning curve and improved operative times in the vast majority of cases studied. FDA DEVICE/DRUG STATUS TrackX (Approved for this indication)

Spinal alignment, particularly with respect to spinopelvic parameters, is highly correlated with morbidity and health-related quality-of-life outcomes. Although the importance of spinal alignment has been emphasized in the deformity literature, spinopelvic parameters have not been considered in the context of spine oncology. Because the aim of oncologic spine surgery is mostly palliative, consideration of spinopelvic parameters could improve postoperative outcomes in both the primary and metastatic tumor population by taking overall vertebral stability into account. This review highlights the relevance of focal and global spinal alignment, particularly related to spinopelvic parameters, in the treatment of spine tumors.

Front-back procedures for cervical deformity permit the correction of cervical kyphosis in the setting of unfused facets. Here, we highlight the operative treatment of a 65-yr-old female entailing a 4-level anterior cervical discectomy and fusion (ACDF) at C3-C4, C4-C5, C5-C6, and C6-C7 with hyperlordotic interbody implants, supplemented by a posterior C2-T2 instrumented fusion. The patient initially presented with symptoms of treatment-refractory neck pain while neurologically intact on examination. Her imaging demonstrated significant cervical kyphosis measuring 46° as the Cobb angle between C2 and C7 without neural compression. The patient consented to the procedure and publication of their image. After 2 d of traction, the operation proceeded with the patient initially in a supine position with dissection medial to the sternocleidomastoid muscle down to the vertebral bodies. Discectomies were performed at each level followed by installation of the interbody implants. After closure of this access wound, the patient was turned to a prone position for the posterior element of the operation. The posterior bony elements were exposed and a C2-T2 instrumented fusion performed. Postoperative imaging demonstrated improvement of her sagittal cervical curvature and the patient described improvement in her neck pain.

OBJECTIVE In patients with metastatic spinal disease (MSD), interhospital transfer can potentially impact clinical outcomes as the possible benefits of transferring a patient to a higher level of care must be weighed against the negative effects associated with potential delays in treatment. While the association of clinical outcomes and transfer status has been examined in other specialties, the relationship between transfer status, complications, and risk of mortality in patients with MSD has yet to be explored. The purpose of this study was to examine the impact of transfer status on in-hospital mortality and clinical outcomes in patients diagnosed with MSD. METHODS The National (Nationwide) Inpatient Sample (NIS) database was retrospectively queried for adult patients diagnosed with vertebral pathological fracture and/or spinal cord compression in the setting of metastatic disease between 2012 and 2014. Demographics, baseline characteristics (e.g., metastatic spinal cord compression [MSCC] and paralysis), comorbidities, type of intervention, and relevant patient outcomes were controlled in a multivariable logistic regression model to analyze the association of transfer status with patient outcomes. RESULTS Within the 10,360 patients meeting the inclusion and exclusion criteria, higher rates of MSCC (50.2% vs 35.9%, p < 0.001) and paralysis (17.3% vs 8.4%, p < 0.001) were observed in patients transferred between hospitals compared to those directly admitted. In univariable analysis, a higher percentage of transferred patients underwent surgical intervention (p < 0.001) when compared with directly admitted patients. After controlling for significant covariates and surgical intervention, transferred patients were more likely to develop in-hospital complications (OR 1.34, 95% CI 1.18–1.52, p < 0.001), experience prolonged length of stay (OR 1.33, 95% CI 1.16–1.52, p < 0.001), and have a discharge disposition other than home (OR 1.70, 95% CI 1.46–1.98, p < 0.001), with no significant difference in inpatient mortality rates. CONCLUSIONS Patients with MSD who were transferred between hospitals demonstrated more severe clinical presentations and higher rates of inpatient complications compared to directly admitted patients, despite demonstrating no difference in in-hospital mortality rates.

The incidence of metastatic spine disease (MSD) is increasing among cancer patients. Given the poor outcomes and high rates of morbidity associated with MSD, it is important to determine demographic factors that could impact interventions and outcomes for this patient population. The objectives of this study were to compare in-hospital mortality and complication rates, clinical presentation, and interventions between female and male patients diagnosed with MSD.Patient data were collected from the United States National Inpatient Sample (NIS) database from the years 2012-2014. Descriptive statistics were used to compare data from 51,800 cases; subsequently, multivariable logistic regression analyses were conducted to assess the effect of gender on outcomes.Males had significantly higher rates of in-hospital mortality (OR 1.30; 95 % CI 1.09-1.56, p = 0.004) and were more likely to have received surgical intervention than females (OR 1.34; 95 % CI 1.16-1.55, p0.001). Additionally, female patients were more likely to present with vertebral compression fracture (p0.001), while metastatic spinal cord compression (MSCC) and paralysis were more common in male patients (p0.001). There was no significant difference in rates of in-hospital complications between female and male patients.Given the significant differences in mortality, disease course, treatment, and in-hospital complications between female and male patients diagnosed with MSD, additional prospective studies are necessary to understand how to meaningfully incorporate these differences into clinical care and prognostication going forward.

Background Early readmission after spine surgery is being used as a proxy for quality of care. One-fifth of patients are rehospitalized within 30 days after spine surgery, and more than one-third within 90 days; however, there is a paucity of data about the cause of early readmissions in elderly patients after elective spine surgery. Methods A total of 500 elderly patients (>65 years old) undergoing elective spine surgery at a major academic hospital were included in the study. We identified all unplanned readmissions within 30 days of discharge. Unplanned readmissions were defined to have occurred as a result of either a surgical or a nonsurgical complication. Patient records were reviewed to determine the cause of readmission and the length of hospital stay. Results A total of 50 (10%) unplanned early readmissions were identified. The mean ± SD age was 72.54 ± 5.84 years. The mean ± SD number of days from discharge to readmission was 11.02 ± 7.25 days, and the average length of hospital stay for the readmissions was 7.7 days. The majority of patients that were readmitted presented to the emergency department from home (46%), whereas 38% were readmitted from a skilled nursing facility. The most common causes for readmission were infection or a concern for infection (42%) and pain (14%), with 32% of readmissions requiring a return to the operating room. Conclusion Our study suggests that in elderly patients undergoing elective spine surgery, infection or a concern for infection, pain, and altered mental status were the most common primary reasons for unplanned readmission.