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Controversy exists regarding the ability of posterior (transforaminal) lumbar interbody fusion (PLIF/TLIF) to achieve lordosis. We hypothesized that an interbody device (IBD) designed for positioning in the anterior disc space produces greater lordosis than IBDs designed for straight-in positioning. The purpose of this study is to determine if using either an anterior-position or straight-in position IBD design were associated with successful achievement of postoperative lordosis.A consecutive series of patients undergoing a undergoing a single-level, posterior open midline (transforaminal) lumbar interbody fusion procedure for degenerative spine conditions during a time period when the two types of interbody devices were being used at surgeon discretion were identified from a multi-surgeon academic training center. Patient demographics and radiographic measures including surgical level lordosis (SLL), anterior disc height, middle disc height, posterior disc height, IBD height, and IBD insertion depth were measured on preop, immediate postop, and one-year postop standing radiographs using PACS. Group comparison and regression analysis were performed using SPSS.Sixty-one patients were included (n=37 anterior, n=34 straight-in). Mean age was 59.8±8.7 years, 32 (52%) were female. There was no difference between IBD type (anterior vs. straight-in) for mean Pre-op SLL (19±7° vs. 20±6°, p=0.7), Post-op SLL (21±5° vs 21±6°, p=0.5), or Change in SLL (2±4° vs. 1±5°, p=0.2). Regression analysis showed that Pre-op SLL was the only variable associated with Change in SLL (Beta = negative 0.48, p=0.000). While the mean Change in SLL could be considered clinically insignificant, there was wide variability: from a loss of 9° to a gain of 13°. Gain of lordosis5° only occurred when Pre-op SLL was21°, and loss of lordosis5° only occurred when Pre-op SLL was21°.While group averages showed an insignificant change in segmental lordosis following a posterior (transforaminal) interbody fusion regardless of interbody device type, pre-operative lordosis was correlated with a clinically significant change in segmental lordosis. Preoperative hypolordotic discs were more likely to gain significant lordosis, while preoperative hyperlordotic discs were more likely to lose significant lordosis. Surgeon awareness of this tendency can help guide surgical planning and technique.

Background Context Although lumbar disc herniation (LDH) classically presents with lower extremity radiculopathy, there are patients who have substantial associated back pain. Purpose The present study aims to determine if patients with LDH with substantial back pain improve with decompression alone. Study Design This is a longitudinal observational cohort study. Patient Sample Patients enrolled in the Quality and Outcomes Database with LDH and a baseline back pain score of ≥5 of 10 who underwent single- or two-level lumbar discectomy only. Outcome Measures Back and leg pain scores (0–10), Oswestry Disability Index (ODI), and EuroQoL 5D were measured. Methods Standard demographic and surgical variables were collected, as well as patient-reported outcomes at baseline and at 3 and 12 months postoperatively. Results The mean age of the cohort was 49.8 years and 1,195 (52.8%) were male. Mean body mass index was 30.1 kg/m2. About half of the patients (1,103, 48.8%) underwent single-level discectomy and the other half (1,159, 51.2%) had two-level discectomy. Average blood loss was 44 cc. Most of the patients (2,217, 98%) were discharged home with routine postoperative care. The average length of stay was 0.53 days. At 3 and 12 months postoperatively, there were statistically significant (p Conclusions Patients with LDH who have substantial back pain can be counseled to expect improvement in their back pain scores 12 months after a discectomy.

BACKGROUND CONTEXT Recent studies suggest as much as 25% of patients undergoing spine surgery are still on opioids two years later. In response, we developed protocols to minimize opioid consumption following elective spine surgery. Our goal was to evaluate patients undergoing single-level Anterior Lumbar Interbody Fusions (ALIF ± posterior fixation) on MMPC compared to patients who were not (nonMMPC). PURPOSE To determine if the combination of an oral preoperative pain cocktail with transverse abdominis plane (TAP) block (multi-modal pain control: MMPC) will reduce length of stay (LOS), ileus, and in-hospital opioid consumption. STUDY DESIGN/SETTING Retrospective chart review. PATIENT SAMPLE Consecutive patients undergoing single-level ALIF for degenerative lumbar conditions by a single-surgeon. OUTCOME MEASURES Length of stay (LOS), incidence of ileus and in-hospital opioid consumption. METHODS A retrospective review of a prospective, single-surgeon, surgical database was utilized for consistency in technique. Consecutive patients undergoing single-level ALIF for degenerative lumbar conditions were identified before and after initiation of the MMPC. The MMPC consisted of a preop oral regimen of cyclobenzaprine (10mg), gabapentin (600mg), acetaminophen (1g) and methadone (10mg). Postoperatively they received a bilateral transverse abdominis plane (TAP) block with 0.5% Ropivicaine. Our primary outcome was total, in-hospital opioid consumption (morphine milligram equivalents: MME). RESULTS There were 68 patients in the MMPC cohort and 39 in the nonMMPC cohort. There was no difference in baseline demographics such as sex, BMI, smoking, or preoperative opioid use between the two groups. The MMPC cohort was older (56.7 vs 51.1 years, p=0.026). Similar rates of ileus (4 vs 6, p=0.102), no difference in LOS (3.8 vs 4.5, p=0.246) and no difference in index hospital costs was found. Although there was no difference in day of surgery MMEs (58.5 vs 68.9, p=0.387), cumulative MMEs each day after surgery was significantly lower in the MMPC cohort, with final cumulative MMEs being reduced by 62% (120.2 vs 314.8, p CONCLUSIONS The use of a MMPC regimen in patients undergoing single-level ALIF for degenerative conditions reduced opioid consumption starting on POD 1, resulting in a cumulative reduction of 62%. Further research should strive to minimize opioid use and the downstream effects. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Previous studies suggest that a postoperative symptom state with Oswestry Disability Index (ODI)≤20 and pain Numeric Rating Scales (NRS)≤2 following surgery for lumbar degenerative conditions are reasonable thresholds for best outcomes in which patients will be unlikely to seek additional medical care or require additional health-care resources. PURPOSE To identify prognostic factors that predict a “best outcome,” defined as postoperative ODI≤20 and pain NRS≤2 following fusion for lumbar degenerative conditions. STUDY DESIGN Longitudinal observational cohort. PATIENT SAMPLE A total of 396 patients from a single site enrolled in the Quality Outcomes Database who underwent fusion for lumbar degenerative conditions. Outcome Measures Oswestry Disability Index, Back and Leg Pain NRS (0–10). METHODS Collected and analyzed variables included age, sex, body mass index, American Society of Anesthesia grade, number of surgical levels, surgical time, preoperative ODI, preoperative back pain, preoperative leg pain, workmen compensation status, surgical approach, smoking status, and principal diagnosis. RESULTS A total of 74 patients (19%) reported a minimal symptom state at 1-year postoperative (ODI≤20, back pain NRS≤2, and leg pain NRS≤2) and were included in the best outcomes group. Patients in the best outcomes group were older (62 vs. 57 years, p=.001), had lower preoperative ODI (43 vs. 56, p=.000), lower preoperative back pain (6.5 vs. 7.5, p=.000). They had fewer surgical levels (1.25 vs. 1.47, p=.005) and shorter operative times [OR] times (208 vs. 241 minutes, p=.002). They were more likely to have a preoperative diagnosis of spondylolisthesis or disc herniation and less likely to have a diagnosis of adjacent segment disease or mechanical disc collapse (p=.001). Stepwise forward regression analysis revealed diagnosis (p=.023, OR=0.75), age (p=.000, OR=1.04), baseline ODI (p=.000, OR=0.96), and number of levels (p=.019, OR=0.53) as predictive variables. CONCLUSION Achieving a minimal symptom state, defined here as a postoperative ODI≤20 and pain NRS≤2, following fusion for lumbar degenerative conditions is more likely in an older patient with a lower baseline ODI undergoing a single level lumbar fusion for spondylolisthesis.

BACKGROUND CONTEXT Posterior fixation with interbody cage placement can be accomplished via numerous techniques. In attempts to expedite recovery by limiting muscle dissection, the midline interbody fusion (MIDLIF) has been described. More recently, we have developed a robotic-assisted MIDLIF (RA-MIDLIF) technique. Introduction of new technology can potentially be expensive and burdensome. PURPOSE The purpose of this study was to compare index episode of care parameters between patients undergoing either traditional open TLIF (tTLIF), MIDLIF, or RA-MIDLIF. STUDY DESIGN/SETTING Retrospective review of a prospective, multisurgeon, surgical database. PATIENT SAMPLE Consecutive patients undergoing 1- or 2- level RA-MIDLIF, tTLIF or MIDLIF. OUTCOME MEASURES Estimated blood loss (EBL), operative tme (OR Time), length of stay (LOS), total direct hospital cost. METHODS A retrospective review of a prospective, multisurgeon, surgical database was utilized. Consecutive patients undergoing 1- or 2-level RA-MIDLIF for degenerative lumbar conditions were identified and propensity-matched based on age, sex, smoking status, BMI, ASA grade and levels fused to patients undergoing tTLIF or MIDLIF. LOS, EBL, OR Time and direct hospital cost for the index surgical admission were compared. RESULTS Of 55 RA-MIDLIF cases identified, 52 were successfully propensity-matched to patients undergoing tTLIF or MIDLIF. Consistent with propensity matching, there was no difference in age, sex, BMI, ASA grade, smoking status or levels fused. The mean direct hospital cost was similar across all cohorts. Patients undergoing RA-MIDLIF had a shorter average LOS (1.53 days) compared to either MIDLIF (2.71 days) or TLIF (3.58 days). Both MIDLIF and RA-MIDLIFs had lower EBL and less OR time compared to both tTLIF. CONCLUSIONS Despite concerns for additional cost and time while introducing navigation or robotic technology, a propensity-matched comparison of our first 52 robotic-assisted MIDLIF surgeries compared to tTLIF and MIDLIF showed promising results for reducing OR time, EBL, LOS and without increasing cost. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Provisions in the Patient Protection and Affordable Care Act (PPAC) include alternative payment models that shift away from fee-for-service reimbursement and provide incentives to improve value. These reimbursement models could incorporate the post-discharge facility care and it is therefore important to identify drivers of additional cost, especially in the setting of unexpected non-home discharge. PURPOSE To identify factors associated with being discharged to a non-home location after an elective 1-2 level instrumented lumbar fusion that, if identified, can be useful to allow for early post-discharge planning. STUDY DESIGN/SETTING Retrospective chart review. PATIENT SAMPLE Patients undergoing 1-2 level instrumented lumbar fusions for degenerative lumbar conditions from 2016 to 2018. OUTCOME MEASURES Non-home discharge. METHODS Hospital administrative database and electronic medical record analysts identified consecutive patients undergoing 1-2 level instrumented lumbar fusions for degenerative lumbar conditions from 2016 to 2018. Discharge disposition was determined as home vs non-home (NH). A regression analysis was used to determine associations between NH discharge and an underserved zip code, ASA grade, marital status, race, insurance type, smoking status, BMI, number of levels, approach and revision surgery. RESULTS A total of 1,502 patients (601; 40% male) were included with a mean age of 57.5 years. The majority were discharged home (1,216; 81%). Of the 286 (19%) not discharged home, the majority went to a skilled nursing facility (248). Factors associated with a NH discharge were living in an underserved zip code, not being married, being on government insurance, having more levels fused, higher BMI and older age. Length of stay (5.64 vs 3.03 days, p CONCLUSIONS Patients living in an underserved zip code, not married, higher BMI, older, and having government insurance are more likely to be discharged to a non-home facility after undergoing 1-2 instrumented lumbar fusions. Identification and early intervention to place these patients even before admission may decrease the length of hospital stay and cost. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT In 2016 alone, 19,413 deaths were attributed to prescription opioid overdoses. Understanding the drivers of opiate consumption in postoperative lumbar spinal fusion patients is a high priority. PURPOSE To determine if surgical invasiveness and/or preoperative opiate use influences immediate postoperative opiate consumption. STUDY DESIGN/SETTING Propensity matched longitudinal cohort. PATIENT SAMPLE Patients from a multi-surgeon, single spine specialty center with degenerative lumbar pathology who underwent an instrumented posterior lumbar decompression and interbody fusion (MIDLIF or TLIF). OUTCOME MEASURES Oswestry Disability Index, morphine equivalent doses (MED) from postoperative day (POD) #0 through POD #4. METHODS A single-center, multi-surgeon, retrospective review identified patients with degenerative lumbar pathology who underwent an instrumented posterior lumbar decompression and interbody fusion (MIDLIF or TLIF). Patients in each cohort were propensity-matched based on age, sex, smoking status, BMI, diagnosis, ASA grade and levels fused. MED POD #0 through POD #4 were calculated. Preoperative opiate prescriptions were recorded to determine baseline opioid use. RESULTS Of 214 MIDLIF and 281 TLIF patients undergoing surgery, 33 patients in each cohort were successfully propensity matched with no differences in baseline characteristics. There was no difference in immediate postoperative mean total MED between the cohorts (MIDLIF=370, TLIF=302, p=.398). Forty-three (65%) of patients were taking opiates prior to surgery. Opiate-naive patients required less narcotics (MED=248) compared to nonopiate naive patients (MED=383, p=.071) but this was not significant. Patients taking opiates preop had worse baseline ODI (56.5 vs. 47.2, p=.023) and 1-year postop ODI (46.3 vs. 30.9, p=.015). CONCLUSIONS Neither surgical invasiveness nor preoperative opiate use have an impact on immediate postop opiate consumption. This is likely secondary to non-individualized prescribing patterns. Patients taking preop narcotics have worse baseline, 1-year, and improvement in ODI following 1- and 2-level MIDLIFs or TLIFs. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Posterior instrumented lumbar fusions are commonly performed utilizing interbody fusions. Recently, a minimally invasive technique of midline exposure with cortical bone trajectory screw fixation has been described (MIDLIF). The goal is to limit muscle dissection, decreasing surgical morbidity and expedite recovery. PURPOSE The purpose of this study was to compare index episode of care (iEOC) cost between patients undergoing MIDLIF versus tTLIF. STUDY DESIGN/SETTING Multi-surgeon single-center spine specialty tertiary practice. PATIENT SAMPLE Consecutive patients undergoing 1- or 2-level MIDLIF or tTLIF for degenerative lumbar conditions were identified. OUTCOME MEASURES Index episode of care cost data for surgical and hospital stay parameters and included actual, direct, hospital cost. METHODS A retrospective review of a prospective, multi-surgeon, surgical database was utilized. Consecutive patients undergoing 1- or 2-level MIDLIF or tTLIF for degenerative lumbar conditions were identified. Patients in each cohort were propensity-matched based on age, sex, smoking status, BMI, diagnosis, ASA grade and levels fused. iEOC cost data was collected for surgical and hospital stay parameters and included actual, direct, hospital cost for the index surgical visit. RESULTS Of 214 and 281 patients undergoing MIDLIF or tTLIF, respectively, 105 cases in each cohort were successfully propensity-matched. Consistent with propensity matching, there was no difference in age, sex, BMI, diagnosis, ASA score, smoking status, or levels fused. Spondylolisthesis was the most common indication for surgery in both cohorts. The mean total iEOC was $706 ($16,604 vs. $17,310) lower for MIDLIF versus tTLIF. There was no difference in implant (p=.193) or biologic (p=.145) cost but blood utilization (p=.000), OR supplies (p=.000), hospital room/board (p=.000), pharmacy (p=.010), and therapy (p=.009) costs were all significantly lower in MIDLIF. Additionally, mean LOS was decreased for MIDLIF (2.97 vs. 4.02, p=.000). CONCLUSIONS Compared to traditional open tTLIF, patients undergoing MIDLIF have several cost parameters of the iEOC that are significantly lower as well as a shorter length of stay. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Background Context Obesity is a growing problem in health care. Studies have demonstrated similar functional outcomes but higher complication rates after spine surgery in obese patients. Purpose This study aimed to compare patient-reported outcomes and revision rates 5 years after instrumented posterior lumbar fusion between normal, overweight, and obese patients. Study design Propensity matched case control. Patient sample Patients who had posterior instrumented lumbar spinal fusion from 2001 to 2008 from a single spine specialty center with complete preoperative and 5-year postoperative outcome measures were identified. Outcome measures Oswestry Disability Index (ODI), Back Pain (0–10) and Leg Pain (0–10) Numeric Rating Scales, and Short Form-36 Physical Composite Summary Scores (SF-36 PCS). Methods Three comparison groups, one with body mass index (BMI) ≥20–25 kg/m 2 (normal), another with ≥25– 2 (overweight), and another with ≥30–40 kg/m 2 (obese) were created using propensity matching techniques based on demographics, baseline clinical outcome measures, and surgical characteristics. Five-year postoperative outcome measures and revision rates in the three groups were compared. One-way analysis of variance was used to compare continuous variables, and Fisher exact test was used to compare categorical variables between the groups. Significance was set at p Results There were 82 cases matched in each cohort. Estimated blood loss (440 cc vs. 702 cc vs. 798 cc, p=.000) and operative time (234 minutes vs. 263 minutes vs. 275 minutes, p=.003) were significantly greater in the overweight and obese patients. Improvements in ODI (14.2 vs. 9.6 vs. 10.4, p=.226), SF-36 PCS (5.9 vs. 2.9 vs. 3.5, p=.361), back pain (3.0 vs. 2.0 vs. 2.1, p=.028), and leg pain (3.0 vs. 2.3 vs. 2.3, p=.311) scores were similar among the groups. Revision rates (14 vs. 15 vs. 13, p=.917), and time between index and revision surgery (p=.990) were similar among the three groups as well. Conclusion When considering a subset of patient-reported outcomes and revision surgery after 5 years, patients with an elevated BMI >25 at baseline did not appear to have worse outcomes than those with a normal BMI of 20–25 when undergoing posterior lumbar fusion surgery. Obesity should not be considered a contraindication to surgery in patients with appropriate surgical indications.