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This was a retrospective cohort study.To determine the extent to which the upper cervical spine compensates for malalignment in the subaxial cervical spine, and how changes in upper cervical spine sagittal alignment affect patient-reported outcomes.Previous research has investigated the relationship between clinical outcomes and radiographic parameters in the subaxial cervical spine following anterior cervical discectomy and fusion (ACDF). However, limited research exists regarding the upper cervical spine (occiput to C2), which accounts for up to 40% of neck movement and has been hypothesized to compensate for subaxial dysfunction.Patients undergoing ACDF for cervical radiculopathy and/or myelopathy at a single center with minimum 1-year follow-up were included. Radiographic parameters including cervical sagittal vertical axis, C0 angle, C1 inclination angle, C2 slope, Occiput-C1 angle (Oc-C1 degrees), Oc-C2 degrees, Oc-C7 degrees, C1-C2 degrees, C1-C7 degrees, and C2-C7 degrees cervical lordosis (CL) were recorded preoperatively and postoperatively. Delta (Δ) values were calculated by subtracting preoperative values from postoperative values. Correlation analysis as well as multiple linear regression analysis was used to determine relationships between radiographic and clinical outcomes. Alpha was set at 0.05.A total of 264 patients were included (mean follow-up 20 mo). C2 slope significantly decreased for patients after surgery (Δ=-0.8, P =0.02), as did parameters of regional cervical lordosis (Oc-C7 degrees, C1-C7 degrees, and C2-C7 degrees; P0.001,0.001, and 0.01, respectively). Weak to moderate associations were observed between postoperative CL and C1 inclination ( r =-0.24, P0.001), Oc-C1 degrees ( r =0.59, P0.001), and C1-C2 degrees ( r =-0.23, P0.001). Increased preoperative C1-C2 degrees and Oc-C2 degrees inversely correlated with preoperative SF-12 Mental Composite Score (MCS-12) scores ( r =-0.16, P =0.01 and r =-0.13, P =0.04). Cervical sagittal vertical axis was found to have weak but significant associations with Short Form-12 (SF-12) Physical Composite Score (PCS-12) ( r =-0.13, P =0.03) and MCS-12 ( r =0.12, P =0.05).No clinically significant relationship between upper cervical and subaxial cervical alignment was detected for patients undergoing ACDF for neurological symptoms. Upper cervical spine alignment was not found to be a significant predictor of patient-reported outcomes after ACDF.Level III.

Background: Currently, no authors of existing studies have attempted to classify the signal characteristics of disc herniation on magnetic resonance imaging (MRI) and their temporal relationship to symptoms of lumbar radiculopathy. The purpose of this study was to determine whether the MRI signal characteristics are predictive of acuity of symptoms in patients with lumbar disc herniation (LDH). Methods: A retrospective cohort study was conducted on patients treated at an academic center for LDH from 2015 to 2018. Patients were divided into 2 groups based on symptom duration (acute: ≤6 weeks; or chronic: >4 months). Two independent observers measured T1, T2 signal, and other MRI characteristics at the affected disc level. Univariate analysis was used to compare differences between groups. Multiple logistic regression was used to determine predictors of acuity. Results: Eighty-nine patients were included (33 acute, 56 chronic) with no significant baseline differences between groups. Rater 2 observed a higher proportion of disc bulges in the chronic group (P = .021) and a higher abnormal T1 herniation signal in the acute group (P = .048). Rater 1 found a higher Pfirrmann grade (P = .005) and a higher prevalence of vertebral body spurring (P = .007) in the chronic group. Interobserver agreement for T1 central and herniation signals demonstrated poor to fair agreement, whereas the remainder of the measurements showed moderate to substantial agreement (κ = 0.4–0.8). Multiple logistic regression showed that Pfirrmann Grade 5 (odds ratio = 0.12, 95% confidence interval [0.02, 0.74], P = .022) and anterior/posterior spurring (odds ratio = 0.053 [0.03, 0.85], P = .023) were not associated with acuity. Conclusions: Other than Pfirrmann grade or vertebral body spurring, no MRI characteristics could be reliably identified that correlate with acuity of symptoms. Level of Evidence: 3.

Cervical and lumbar degenerative disc disease are well-known causes of neck and back pain and associated radiculopathy in spine patients. The estimated 1-year incidence rate of neck pain and any episode of lower back pain is 10.4% to 21.3%[1][1],[2][2] and 1.5% to 36%,[3][3] respectively. Previous

BACKGROUND: The presence of predominant pain in the arm vs the neck as a predictor of postoperative outcomes after anterior cervical discectomy and fusion (ACDF) has been seldom reported; therefore, the purpose of this study was to determine whether patients with predominant neck pain improve after surgery compared to patients with predominant arm pain or those with mixed symptoms in patients undergoing ACDF for radiculopathy. METHODS: A retrospective cohort study was conducted on patients who underwent ACDF at a single center from 2016 to 2018. Patients were split into groups based on preoperative neck and arm pain scores: neck (N) pain dominant group (visual analog scale [VAS] neck ≥ VAS arm by 1.0 point); neutral group (VAS neck < VAS arm by 1.0 point); or arm (A) pain dominant group (VAS arm ≥ VAS neck by 1.0 point), using a threshold difference of 1.0 point. Subsequently, individuals were substratified into 2 groups based on the arm to neck pain ratio (ANR): non-arm pain dominant defined as ANR ≤1.0 and arm pain dominant (APD) defined as ANR >1.0. Patient-reported outcome measurements including Neck Disability Index (NDI), Physical Component Score-12, and Mental Component Score (MCS-12) were compared between groups. RESULTS: No significant differences between groups when stratifying patients using a threshold difference of 1.0 point. When stratifying patients using the ANR, those in the APD group had significantly higher postoperative MCS-12 (P = 0.008) and NDI (P = 0.011) scores. In addition, the APD group showed a greater magnitude of improvement for MCS-12 and NDI scores (P = 0.043 and P = 0.038, respectively). Multiple linear regression showed that the A and the APD groups were both independent predictors of improvement in NDI. CONCLUSION: Patients with dominant arm pain showed significantly greater improvement in terms of MCS-12 and NDI scores compared to patients with dominant neck pain. CLINICAL RELEVANCE: To compare the impact of ACDF on arm and neck pain in the context of cervical radiculopathy using patient-reported outcome measures as an objective measurement. LEVEL OF EVIDENCE: 3.

Study design Retrospective cohort study. Objective The aim of this study was to determine whether the presence of a fellow or resident (F/R) compared to a physician assistant (PA) affected surgical variables or short-term patient outcomes. Summary of background data Although orthopedic spine fellows and residents must participate in minimum number of decompression surgeries to gain competency, the impact of trainee presence on patient outcomes has not been assessed. Methods One hundred and seventy-one patients that underwent a one- to three-level lumbar spine decompression procedure at a high-volume academic center were retrospectively identified. Operative reports from all cases were examined and patients were placed into one of two groups based on whether the first assist was a F/R or a PA. Univariate analysis was used to compare differences in total surgery duration, 30-day and 90-day readmissions, infection and revision rates, patient-reported outcome measures (Short Form-12 Physical Component Score and Mental Component Score, Oswestry Disability Index, Visual Analog Scale [VAS] Back, VAS Leg) between groups. Multiple linear regression was used to assess change in each patient reported outcome and multiple binary logistic regression was used to determine significant predictors of revision, infection, and 30- or 90-day readmission. Results Seventy-eight patients were included in the F/R group compared to 93 patients in the PA group. There were no differences between groups for total surgery time, 30-day or 90-day readmissions, infection, or revision rates. Using univariate analysis, there were no differences between the two groups pre- or postoperatively (P > 0.05). Using multivariate analysis, presence of a surgical trainee did not significantly influence any patient reported outcome and did not affect infection, revision, or 30- and 90-day readmission rates. Conclusion This is one of the first studies to show that the presence of an orthopedic spine fellow or resident does not affect patient short-term outcomes in lumbar decompression surgery. Level of evidence 3.

Study design This was a prospective cohort study. Objective The objective of this study was to design and test a novel spine neurological examination adapted for telemedicine. Summary of background data Telemedicine is a rapidly evolving technology associated with numerous potential benefits for health care, especially in the modern era of value-based care. To date, no studies have assessed whether. Methods Twenty-one healthy controls and 20 patients with cervical or lumbar spinal disease (D) were prospectively enrolled. Each patient underwent a telemedicine neurological examination as well as a traditional in-person neurological examination administered by a fellowship trained spine surgeon and a physiatrist. Both the telemedicine and in-person tests consisted of motor, sensory, and special test components. Scores were compared via univariate analysis and secondary qualitative outcomes, including responses from a satisfaction survey, were obtained upon completion of the trial. Results Of the 20 patients in the D group, 9 patients had cervical disease and 11 patients had lumbar disease. Comparing healthy control with the D group, there were no significant differences with respect to all motor scores, most sensory scores, and all special tests. There was a high rate of satisfaction among the cohort with 92.7% of participants feeling "very satisfied" with the overall experience. Conclusions This study presents the development of a viable neurological spine examination adapted for telemedicine. The findings in this study suggest that patients have comparable motor, sensory, and special test scores with telemedicine as with a traditional in-person examination administered by an experienced clinician, as well as reporting a high rate of satisfaction among participants. To our knowledge, this is the first telemedicine neurological examination for spine surgery. Further studies are warranted to validate these findings.

Study Design: Retrospective cohort study. Objective: The goal of this study was to determine whether the absolute size (mm2), relative size (% canal compromise), or location of a single-level, lumbar disc herniation (LDH) on axial and sagittal cuts of magnetic resonance imaging (MRI) were predictive of eventual surgical intervention. Methods: MRIs of 89 patients were reviewed, and patients were split into groups based on type of management received (34 nonoperative vs 55 microdiscectomy). Radiographic characteristics—including size of disc herniation (mm2), size of spinal canal (mm2), location of herniation on axial (central, paracentral, foraminal) and sagittal (disc level, suprapedicle, pedicle, infrapedicle) planes, and type of herniation (bulge, protrusion, extrusion, sequestration)—were measured by 2 independent, orthopedic spine fellows and compared between groups via univariate and multivariate analyses. Results: The operative group showed a significantly higher percentage of canal compromise (39.5% vs 31.1%, P = .001) compared to the nonoperative group. Multiple logistic regression analysis showed higher odds of eventual operative intervention for a disc protrusion (odds ratio [OR] 6.30 [1.99, 19.86], P = .002) or disc extrusion (OR 11.5 [1.63, 81.2], P = .014) for Rater 1 and a higher odds of eventual surgical management for a paracentral location for both Rater 1 and Rater 2 (OR = 3.39 [1.25, 9.22], P = .017, and OR = 5.46 [1.77, 16.8], P = .003, respectively). Conclusions: Disc herniations in a paracentral location were more likely to undergo operative treatment than those more centrally located, on axial MRI views.

Study design A single center, observational prospective clinical study. Objective The aim of this study was to compare the instrumentation-related cost and efficiency of single-use instrumentation versus traditional reusable instrument trays. Summary of background data Single-use instrumentation provides the opportunity to reduce costs associated with cleaning and sterilizing instrumentation after surgery. Although previous studies have shown single-use instrumentation is effective in other orthopedic specialties, it is unclear if single-use instrumentation could provide economic advantages in spine surgery. Materials and methods A total of 40 (20 reusable instrumentation and 20 single-use instrumentation) lumbar decompression (1-3 level) and fusion (1 level) spine surgeries were collected. Instrument handling, opening, setup, re-stocking, cleaning, sterilization, inspection, packaging, and storage were recorded by direct observation for both reusable and single-use instrumentation. The rate of infection was noted for each group. Results Mean time of handling instruments by the scrub nurse was 11.6 (±3.9) minutes for reusable instrumentation and 2.1 (±0.5) minutes for single-use instrumentation. Mean cost of handling reusable instruments was estimated to be $8.52 (±$2.96) per case, and the average cost to reprocess a single tray by Sterilization Processing Department (SPD) was $58. Thus, the median cost for sterilizing 2 reusable trays per case was $116, resulting in an average total Costresuable of $124.52 (±$2.96). Mean cost of handling single-use instrumentation was estimated to be $1.57 ($0.38) per case. Conclusion Single-use instrumentation provided greater cost savings and reduced time from the opening of instrumentation to use in surgery when compared with reusable instrumentation.

Study Design: Retrospective cohort study. Objective: The goal of this study was to determine how smoking status influences patient-reported outcome measurements (PROMs) in patients undergoing lumbar decompression surgery. Methods: Patients undergoing lumbar decompression between 1 to 3 levels at a single-center, academic hospital were retrospectively identified. Patients Results: A total of 195 patients were included in the final cohort, with 121 (62.1%) patients in the NS group, 22 (11.3%) in the CS group, and 52 (26.6%) in the FS group. There were no significant differences between groups at baseline or postoperatively. Smoking status was also not a significant predictor of change in any outcome scores over time on multivariate analysis. Conclusion: These results suggest that smoking status does not significantly affect short-term complications or outcomes in patients undergoing lumbar decompression surgery.

Study design This is a retrospective case review. Objective The objective of this study was to present an anatomic approach to transpsoas interbody fusion without psoas stimulated electromyography (sEMG) and to evaluate the rate of neurological and approach-related complications. Background The transpsoas approaches have become commonly utilized for lumbar interbody fusion and may have certain advantages compared with other methods of interbody stabilization. Traditionally, transpsoas approaches have been performed utilizing sEMG as it has been purported to reduce the risk of injury to the lumbar plexus; however, an anatomic approach to transpsoas surgery is also possible as cadaveric studies have demonstrated the anatomy of the psoas muscle and lumbar plexus. Methods Patients who underwent transpsoas interbody fusion using an anatomic approach without psoas sEMG between 2005 and 2018 were enrolled in this study. The preoperative and postoperative medical records for this cohort were carefully reviewed to identify any new or persistent radicular symptoms, neurological deficits or approach-related complications. Results A total of 133 patients (48 males, 85 females) underwent transpsoas interbody fusion at 222 levels in this cohort-which had a mean age of 63 (61, 65) years and body mass index of 28.8 (27.8, 29.9). New neurological complications were seen in 5 patients (3.8%) and 5 patients (3.8%) were found to have new postoperative radicular pain, up to 3 months postoperatively. The total number of perioperative, approach-related complications was 7 (5.3%) for the entire cohort. Conclusion An anatomic transpsoas approach to the interbody space without psoas sEMG demonstrated a rate of neurological and approach-related complications that was comparable or superior to the rate of complications reported using the traditional transpsoas approach with sEMG.

This is a retrospective comparative review.The objective of this study was to identify the influence of body mass index (BMI) on postsurgical complications and patient reported outcomes measures (PROMs) following lumbar decompression surgery.Current literature does not accurately identify the impact of BMI on postsurgical complications or outcomes.Records from a single-center, academic hospital were used to identify patients undergoing 1 to 3-level lumbar decompression surgery. Patients under 18 years of age, those undergoing surgery for infection, trauma, tumor, or revision, and those with1-year follow-up were excluded. Patients were split into groups based on preoperative BMI: class I: BMI25.0 kg/m; class II: BMI 25.0-29.9 kg/m; class III: BMI 30.0-34.9 kg/m; and class IV: BMI35.0 kg/m. Absolute PROM scores, the recovery ratio and the percent of patients achieving minimum clinically important difference between groups were compared and a multiple linear regression analysis was performed.A total of 195 patients were included with 34 (17.4%) patients in group I, 80 (41.0%) in group II, 49 (25.1%) in group III, and 32 (16.5%) in group IV. Average age was 60.0 (58.0, 62.0) years and average follow-up was 13.0 (12.6, 13.4) months. All patients improved significantly within each group, except for class III and class IV patients, who did not demonstrate significant improvements in terms of Mental Component Score (MCS-12) scores (P=0.546 and 0.702, respectively). There were no significant differences between BMI groups for baseline or postoperative PROM values, recovery ratio, or the percent of patients reaching minimum clinically important difference. Multiple linear regression analysis revealed that BMI was not a significant predictor for change in outcomes for any measure. The 30-day readmission rate was 6.2% and overall revision rate at final follow-up was 5.1%, with no significant differences between groups.This study's results suggest that BMI may not significantly affect complications or patient outcomes at 1-year in those undergoing lumbar decompression surgery.Level III.

STUDY DESIGN Retrospective study. OBJECTIVE The aim of this study was to determine risk factors for prolonged opioid use and to investigate whether opioid-tolerance affects patient-reported outcomes following anterior cervical discectomy and fusion (ACDF) surgery. SUMMARY OF BACKGROUND DATA There is a lack of consensus on risk factors that can affect continued opioid use after cervical spine surgery and the influence of opioid use on patient-reported outcomes. METHODS Ninety-two patients who underwent ACDF for degenerative cervical pathologies were retrospectively identified and their opioid usage before surgery was investigated using a state-sponsored prescription drug monitoring registry. Opioid-naive and opioid tolerant groups were defined using criteria most consistent with the Federal Drug Administration (FDA) definition. Patient-reported outcomes were then collected, including the Short Form-12 (SF-12) Physical Component (PCS-12) and Mental Component (MCS-12), the Neck Disability Index (NDI), the Visual Analogue Scale Neck (VAS neck) and the Visual Analogue Scale Arm (VAS Arm) pain scores. Logistic regression was used to determine predictors for prolonged opioid use following ACDF. Univariate and multivariate analyses were conducted to compare change in outcomes over time between the two groups. RESULTS Logistic regression analysis demonstrated that opioid tolerance was a significant predictor for prolonged opioid use after ACDF (odds ratio [OR]: 18.2 [1.46, 226.4], P = 0.02). Duration of usage was also found to be a significant predictor for continued opioid use after surgery (OR: 1.10 [1.0, 1.03], P = 0.03). No other risk factors were found to be significant predictors. Both groups overall experienced improvements in patient-reported outcomes after surgery. Multiple linear regression analysis, controlling for patient demographics, demonstrated that opioid-tolerant user status positively affected change in outcomes over time for NDI (β = -13.7 [-21.8,-5.55], P = 0.002) and PCS-12 (β = 6.99 [2.59, 11.4], P = 0.003) but no other outcomes measured. CONCLUSION Opioid tolerance was found to be a significant predictor for prolonged opioid use after ACDF. Additionally, opioid-naive and opioid-tolerant users experienced overall improvements across PROMs following ACDF. Opioid-tolerance was associated with NDI and PCS-12 improvements over time compared to opioid-naive users. LEVEL OF EVIDENCE 4.

STUDY DESIGN Retrospective cohort review. OBJECTIVE The objective of this study was to identify depression using the Mental Component Score (MCS-12) of the Short Form-12 (SF-12) survey and to correlate with patient outcomes. SUMMARY OF BACKGROUND DATA The impact of preexisting depressive symptoms on health-care related quality of life (HRQOL) outcomes following lumbar spine fusion is not well understood. METHODS Patients undergoing lumbar fusion between one to three levels at a single center, academic hospital were retrospectively identified. Patients under the age of 18 years and those undergoing surgery for infection, trauma, tumor, or revision, and less than 1-year follow-up were excluded. Patients with depressive symptoms were identified using an existing clinical diagnosis or a score of MCS-12 less than or equal to 45.6 on the preoperative SF-12 survey. Absolute HRQOL scores, the recovery ratio (RR) and the percent of patients achieving minimum clinically important difference (MCID) between groups were compared, and a multiple linear regression analysis was performed. RESULTS A total of 391 patients were included in the total cohort, with 123 (31.5%) patients reporting symptoms of depression based on MCS-12 and 268 (68.5%) without these symptoms. The low MCS-12 group was found to have significantly worse preoperative Oswestry disability index (ODI), visual analogue scale back pain (VAS Back) and visual analogue scale leg pain (VAS Leg) scores, and postoperative SF-12 physical component score (PCS-12), ODI, VAS Back, and VAS Leg pain scores (P

Degenerative lumbar disease can be addressed via an anterior or posterior approach, and with or without the use of an interbody cage. Although several studies have compared the type of approach and technique, there is a lack of literature assessing patient-reported outcome measures (PROMs) and radiographic parameters between different fusion techniques.To determine whether the surgical approach and fusion technique for lumbar degenerative disease had an effect on short-term PROMs and radiographic parameters.Retrospective Cohort Study.Three hundred and ninety-one patients who underwent a 1-3 level lumbar spine fusion procedure at a high-volume academic center were retrospectively identified. Patients were divided into three groups based on the type of fusion they underwent: posterolateral fusion (PLF), anterior lumbar interbody fusion (ALIF), or transforaminal lumbar interbody fusion (TLIF).PROMs: Short Form-12 (SF-12) Physical Component Score (PCS) and Mental Component Score (MCS), Oswestry Disability Index (ODI), Visual Analog Score (VAS) Back, VAS Leg. Spinopelvic measurements: Pelvic Tilt (PT), Sacral Slope (SS), Pelvic Incidence (PI), Lumbar Lordosis (LL), Segmental Lordosis (SL), PI-LL mismatch.Patients with less than 1-year follow-up were excluded from the cohort. Pre- and postoperative spinopelvic measurements were obtained for all patients. Univariate analysis (Chi-squared/Fisher's exact test or ANOVA test with post-hoc Bonferroni test) was used to compare among the three groups in the PROMs and radiographic spinopelvic parameters. Multiple linear regression was used to determine if fusion technique was an independent predictor of change in each patient outcome.Two hundred and sixteen patients were included in the PLF group, 33 patients in the ALIF group, and 142 patients in the TLIF group. The PLF group was significantly older at baseline (p.001) and had lower preoperative diagnosis rates of degenerative scoliosis and disc herniations (p.001), whereas the ALIF group underwent a higher proportion of three-level fusions (p.001). There was no significant difference in spinopelvic parameters preoperatively, however the ALIF group showed significantly more improvement in SL postoperatively (p=.004) than the PLF and TLIF groups. Within each group, SL improved for the PLF and ALIF groups (p=.002 for both), but not for the TLIF group (p=.238). Comparing patient outcomes, the ALIF group reported lower preoperative VAS Leg scores (p=.031), however, this difference resolved postoperatively. Stratifying for preoperative diagnosis, there were no significant differences in outcomes, except for a greater improvement in VAS Leg scores for degenerative scoliosis patients undergoing ALIF. Using multivariate analysis, fusion technique was not found to be a significant predictor of change in any patient outcome or in odds of revision.Lumbar degenerative disease can be treated with several different fusion techniques, however, the relationship between type of fusion and PROMs is not established. Based on the findings in this study, the ALIF group showed greater improvement in SL compared with the PLF and TLIF groups, however, there was no difference noted in overall LL, PI-LL mismatch or other spinopelvic parameters. Despite these radiographic findings, patient outcome measures remained similar between all three fusion types.

Background: While the impact of trainee involvement in other surgical fields is well established, there is a paucity of literature assessing this relationship in orthopaedic spine surgery. The goal of this study was to further elucidate this relationship. Methods: A retrospective cohort study was initiated on patients undergoing 1–3 level lumbar spine fusion at a single academic center. Operative reports from cases were examined, and patients were divided into 2 groups depending on whether a fellow or resident (F/R) or a physician9s assistant (PA) was used as the primary assist. Patients with less than 1-year follow-up were excluded. Multiple linear regression was used to assess change in each patient-reported outcome, and multiple binary logistic regression was used to determine significant predictors of revision, infection, and 30- or 90-day readmission. Results: One hundred and seventy-two patients were included in the F/R group compared with 178 patients in the PA group. No differences existed between groups for total surgery time, length of stay, 30- or 90-day readmissions, infection, or revision rates. No differences existed between groups in terms of patient-reported outcomes preoperatively or postoperatively. In addition, presence of a surgical trainee was not a significant predictor of patient outcomes or rates of infection, overall revision, or 30- and 90-day readmission rates. Conclusions: The results of this study indicate the presence of an orthopaedic spine F/R does not increase complication rates and does not affect short-term patient-reported outcomes in lumbar decompression and fusion surgery. Level of Evidence: 3.

The total health care expenditure in 2017 was $3.5 trillion dollars—an increase of 3.9% over the previous year and up from $2.6 trillion in 2010 (1,2). With these numbers predicted to grow at an annual rate of 5.5%, the Centers for Medicare and Medicaid Services (CMS) have been piloting new programs and payment systems to reduce costs and incentivize physicians and healthcare organizations to provide cost-effective care (2-4). In 1983, medicare introduced the inpatient prospective payment system in the hopes that hospitals and physicians would start to provide more patient care in the outpatient setting. Since then, the number of surgeries performed as outpatient procedures has increased dramatically from 3.7 million in 1981 to over 32.0 million in 2005 (5). In 2017, more than 50% of all outpatient surgeries were conducted in ambulatory surgery centers (ASCs)—a market which is projected to reach $40 billion in 2020 (6).

In July of 2018, the Second International Consensus Meeting (ICM) on Musculoskeletal Infection convened in Philadelphia, PA was held to discuss issues regarding infection in orthopedic patients and to provide consensus recommendations on these issues to practicing orthopedic surgeons. During this meeting, attending delegates divided into subspecialty groups to discuss topics specifics to their respective fields, which included the spine. At the spine subspecialty group meeting, delegates discussed and voted upon the recommendations for 63 questions regarding the prevention, diagnosis, and treatment of infection in spinal surgery. Of the 63 questions, 17 focused on the use of antibiotics in spine surgery, for which this article provides the recommendations, voting results, and rationales.

Study Design: Retrospective cohort review Objectives: Cervical pseudarthrosis is a frequent cause of need for revision anterior cervical discectomy and fusion (ACDF) and may lead to worse patient-reported outcomes. The effect of proton pump inhibitors on cervical fusion rates are unknown. The purpose of this study was to determine if patients taking PPIs have higher rates of nonunion after ACDF. Methods: A retrospective cohort review was performed to compare patients who were taking PPIs preoperatively with those not taking PPIs prior to ACDF. Patients younger than 18 years of age, those with less than 1-year follow-up, and those undergoing surgery for trauma, tumor, infection, or revision were excluded. The rates of clinically diagnosed pseudarthrosis and radiographic pseudarthrosis were compared between PPI groups. Patient outcomes, pseudarthrosis rates, and revision rates were compared between PPI groups using either multiple linear or logistic regression analysis, controlling for demographic and operative variables. Results: Out of 264 patients, 58 patients were in the PPI group and 206 were in the non-PPI group. A total of 23 (8.71%) patients were clinically diagnosed with pseudarthrosis with a significant difference between PPI and non-PPI groups ( P = .009). Using multiple linear regression, PPI use was not found to significantly affect any patient-reported outcome measure. However, based on logistic regression, PPI use was found to increase the odds of clinically diagnosed pseudarthrosis (odds ratio 3.552, P = .014). Additionally, clinically diagnosed pseudarthrosis negatively influenced improvement in PCS-12 scores ( P = .022). Conclusions: PPI use was found to be a significant predictor of clinically diagnosed pseudarthrosis following ACDF surgery. Furthermore, clinically diagnosed pseudarthrosis negatively influenced improvement in PCS-12 scores.

Retrospective cohort.Determine the effect of duration of symptoms (DOS) on health-related quality of life (HRQOL) outcomes for patients with cervical radiculopathy.The effect of DOS has not been extensively evaluated for cervical radiculopathy.A retrospective analysis of patients who underwent an anterior cervical decompression and fusion for radiculopathy was performed. Patients were grouped based on DOS of less than 6 months, 6 months to 2 years, and more than 2 years and HRQOL outcomes were evaluated.A total of 216 patients were included with a mean follow-up of 16.0 months. There were 86, 61, and 69 patients with symptoms for less than 6 months, 6 months to 2 years, and more than 2 years, respectively. No difference in the absolute postoperative score of the patient reported outcomes was identified between the cohorts. However, in the multivariate analysis, radiculopathy for more than 2 years predicted lower postoperative Short Form-12 Physical Component Score (P = 0.037) and Short Form-12 Mental Component Score (P = 0.029), and higher postoperative Neck Disability Index (P = 0.003), neck pain (P = 0.001), and arm pain (P = 0.004) than radiculopathy for less than 6 months. Furthermore, the recovery ratios for patients with symptoms for less than 6 months demonstrated a greater improvement in NDI, neck pain, and arm pain than for 6 months to 2 years (P = 0.041; 0.005; 0.044) and more than 2 years (P = 0.016; 0.014; 0.002), respectively.Patients benefit from spine surgery for cervical radiculopathy at all time points, and the absolute postoperative score for the patient reported outcomes did not vary based on the duration of symptoms; however, the regression analysis clearly identified symptoms for more than 2 years as a predictor of worse outcomes, and the recovery ratio was statistically significantly improved in patients who underwent surgery within 6 months of the onset of symptoms.3.

BACKGROUND: The pedicle screw is the most common device used to achieve fixation in fusion of spondylolistheses. Safe and accurate placement with this technique relies on a thorough understanding of the bony anatomy. There is a paucity of literature comparing the surgically relevant osseous anatomy in patients with a degenerative spondylolisthesis (DS) and an isthmic spondylolisthesis (IS). The goal of this study was to determine the differences in the osseous anatomy in patients with a DS and those with an IS. METHODS: A retrospective comparative cohort study was conducted on patients with a single-level, symptomatic L4-L5 DS or a single-level, symptomatic L5-S1 IS. Magnetic resonance imaging for these patients was reviewed. Morphometries of the pedicle and vertebral body were analyzed by 2 independent observers for the levels from L3 to S1, and radiographic parameters were compared between groups. RESULTS: A total of 572 levels in 143 patients were studied, including 103 patients with a DS and 40 with an IS. After accounting for confounders, IS and DS had an independent effect on transverse vertebral body width, pedicle height and width, and sagittal pedicle angle. Patients with an IS had a smaller pedicle height (P < .001) and pedicle width (P = .001) than patients with DS. In addition, the angulation of the pedicles varied on the basis of the diagnosis. CONCLUSIONS: The osseous anatomy is significantly different in patients with a DS than with an IS. Patients with an IS have smaller pedicles in the lumbar spine. Also, the L4 and L5 pedicles are more caudally angulated and the S1 pedicle is less medialized. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: Understanding the differences in pedicle anatomy is important for the safe placement of pedicle screws.

BACKGROUND: Currently, no studies have assessed what effect the presence of both anxiety and depression may have on patient-reported outcome measurements (PROMs) compared to patients with a single or no mental health diagnosis. METHODS: Patients undergoing 1- to 3-level lumbar fusion at a single academic hospital were retrospectively queried. Anyone with depression and/or anxiety was identified using an existing clinical diagnosis in the medical chart. Patients were separated into 3 groups: no depression or anxiety (NDA), depression or anxiety alone (DOA), and combined depression and anxiety (DAA). Absolute PROMs, recovery ratios, and the percentage of patients achieving minimal clinically important difference (% MCID) between groups were compared using univariate and multivariate analysis. RESULTS: Of the 391 patients included in the cohort, 323 (82.6%) were in the NDA group, 37 (9.5%) in the DOA group, and 31 (7.9%) in the DAA group. Patients in the DAA group had significantly worse outcome scores before and after surgery with respect to Short Form-12 mental component score (MCS-12) and Oswestry Disability Index (ODI) scores (P

Study design: Retrospective comparative study. Objective: Whereas smoking has been shown to affect the fusion rates for patients undergoing an anterior cervical discectomy and fusion (ACDF), the relationship between smoking and health-related quality of life outcome measurements after an ACDF is less clear. The purpose of this study was to evaluate whether smoking negatively affects patient outcomes after an ACDF for cervical degenerative pathology. Methods: Patients with tumor, trauma, infection, and previous cervical spine surgery and those with less than a year of follow-up were excluded. Smoking status was assessed by self-reported smoking history. Patient outcomes, including Neck Disability Index, Short Form 12 Mental Component Score, Short Form 12 Physical Component Score (PCS-12), Visual Analogue Scale (VAS) arm pain, VAS neck pain, and pseudarthrosis rates were evaluated. Outcomes were compared between smoking groups using multiple linear and logistic regression, controlling for age, sex, and body mass index (BMI), among other factors. A P value Results: A total of 264 patients were included, with a mean follow-up of 19.8 months, age of 53.1 years, and BMI of 29.6 kg/m2. There were 43 current, 69 former, and 152 nonsmokers in the cohort. At baseline, nonsmokers had higher PCS-12 scores than current smokers ( P = .010), lower VAS neck pain than current ( P = .035) and former ( P = .014) smokers, as well as lower VAS arm pain than former smokers ( P = .006). Postoperatively, nonsmokers had higher PCS-12 scores than both current ( P = .030) and former smokers ( P = .035). Smoking status was not a significant predictor of change in patient outcome in multivariate analysis. Conclusions: Whereas nonsmokers had higher function and lower pain than former or current smokers preoperatively, smoking status overall was not found to be an independent predictor of outcome scores after ACDF. This supports the notion that smoking status alone should not deter patients from undergoing ACDF for cervical degenerative pathology.

STUDY DESIGN Retrospective cohort study. OBJECTIVE The goal of the present study was to determine whether neck pain responds differently to anterior cervical discectomy and fusion (ACDF) between patients with cervical radiculopathy and/or cervical myelopathy. SUMMARY OF BACKGROUND DATA Many patients who undergo ACDF because of radiculopathy/myelopathy also complain of neck pain. However, no studies have compared the response of significant neck pain to ACDF. METHODS Patients undergoing one to three-level primary ACDF for radiculopathy and/or myelopathy with significant (Visual Analogue Scale [VAS] ≥ 3) neck pain and a minimum of 1-year follow-up were included. Based on preoperative symptoms patients were split into groups for analysis: radiculopathy (R group), myelopathy (M group), or both (MR group). Groups were compared for differences in Health Related Quality of Life outcomes: Physical Component Score-12, Mental Component Score (MCS)-12, Neck Disability Index, VAS neck, and VAS arm pain. RESULTS Two hundred thirty-five patients met inclusion criteria. There were 117 patients in the R group, 53 in the M group, and 65 in the MR group. Preoperative VAS neck pain was found to be significantly higher in the R group versus M group (6.5 vs. 5.5; P = 0.046). Postoperatively, all cohorts experienced significant (P

C2 tilt and C2 slope are quick and easy measurements to obtain on lateral radiographs and may be used to determine overall cervical sagittal alignment; however, the influence of these measurements on patient outcomes has not been well established in literature.To determine if C2 tilt and/or C2 slope predict patient outcomes better compared with conventional radiographic measures after an anterior cervical discectomy and fusion (ACDF).Retrospective cohort study.A total of 249 patients who underwent 1 to 3 level ACDF to address radiculopathy and/or myelopathy at a single academic institution between 2011 and 2015 were identified. Patients with less than 1 year of follow-up were excluded.Patient Reported Outcomes: Neck Disability Index (NDI), Physical Component Score-12 (PCS-12), and Mental Component Score (MCS-12), Visual Analog Score (VAS) Neck and Arm scores Cervical radiographic measurements: C2 tilt, C2 slope, C2-C7 lordosis, cervical SVA, T1 slope, T1 slope minus cervical lordosis (TS-CL), and C2-C7 ROM METHODS: Pearson correlation tests were performed to assess for significant associations between radiographic measurements and patient outcomes. Multiple linear regression models were developed adjusting for demographics and radiographic parameters to determine which factors were predictive of patient outcomes.C2 tilt and TS-CL correlated with all postoperative physical outcome scores (NDI, PCS-12, VAS Neck and ARM; p.05), however no association was seen between C2 slope and postoperative outcomes. After accounting for the presence of subaxial deformity, C2 tilt and TS-CL remained strongly correlated to patient outcome scores. With multiple linear regression, C2 tilt was a significant predictor for NDI, whereas TS-CL was a significant predictor for PCS-12, VAS Neck and VAS Arm.C2 tilt significantly correlated with well-described conventional cervical parameters as well as postoperative physical outcomes measures, especially NDI, on multivariate analysis. C2 tilt may provide an easy and practical tool for predicting physical outcomes after ACDF.

There are vast numbers of evidenced-based clinical trials produced each year, making it increasingly difficult to stay up to date with new treatments and protocols designed to provide the most optimal patient care. A physician's ability to combine existing knowledge with new data is limited by a basic understanding of the background statistics used in these studies. Our goal is to not only define the basic statistics commonly used in clinical trials but to also ensure that practitioners are able to have a working understanding of these statistical measurements to effectively make the most informed and efficacious decisions regarding patient management. On the basis of the recent growth of empirical spine literature, it is becoming more important for spine surgeons to have the basic statistical background necessary to efficiently interpret new data, which may affect clinical decision making regarding patient care.

BACKGROUND: The Neck Disability Index (NDI) is a 10-item questionnaire about symptoms relevant to cervical spine pathology, originally validated in the physical therapy literature. It is unclear if all of the items apply to spine surgery. The purpose of this study was to determine if improvements in the composite NDI score or specific NDI domains are appropriate measures for tracking changes in physical function after surgical intervention for cervical spondylotic myelopathy (CSM). METHODS: A retrospective cohort review of patients treated at a major academic medical center was undertaken. Baseline and postoperative standardized outcome measurement scores, including composite NDI, NDI subdomain, and SF-12 physical component score (PCS), were collected. Wilcoxon signed-rank test was used to determine whether patients exhibited improvement in each of the outcome measures included. Multiple linear regression was performed to determine whether change in NDI composite or subdomain scores predicted change in physical function after surgery for CSM—compared with the well-validated PCS score—controlling for factors such as age, sex, etc. RESULTS: Baseline data were collected on 118 patients. All outcome measures exhibited significant improvement after surgery based on the Wilcoxon signed-rank test. On linear regression, work (β = −2.419 [−3.831, −1.006]; P = .001) and recreation (β = −1.354 [−2.640, −0.068]; P = .039), as well as the NDI composite score (β = −0.223 [−0.319, −0.127]; P

This is a retrospective cohort study.The objective of this study was to further elucidate the relationship between pelvic incidence-lumbar lordosis (PI-LL) mismatch and surgical outcomes in patients undergoing short segment lumbar fusions for degenerative lumbar disease.There are few studies examining the relationship between spinopelvic parameters and patient reported outcome measurements (PROMs) in short segment lumbar degenerative disease.A retrospective review was conducted at single academic institution. Patients undergoing 1- or 2-level lumbar fusion were retrospectively identified and separated into 2 groups based on postoperative PI-LL mismatch ≤10 degrees (NM) or PI-LL mismatch10 degrees (M). Outcomes including the Physical Component Score (PCS)-12, Mental Component Score (MCS)-12, Oswestry Disability Index (ODI), Visual Analog Scale (VAS) back and leg scores were analyzed. Absolute PROM scores, the recovery ratio and the percentage of patients achieving minimum clinically important difference between groups were compared and a multiple linear regression analysis was performed.A total of 306 patients were included, with 59 patients in the NM group and 247 patients in the M group. Patients in the M group started with a higher degree of PI-LL mismatch compared with the NM group (22.2 vs. 7.6 degrees, P0.001) and this difference increased postoperatively (24.7 vs. 2.5 degrees, P0.001). There were no differences between the 2 groups in terms of baseline, postoperative, or Δ outcome scores (P0.05). In addition, having a PI-LL mismatch was not found to be an independent predictor of any PROM on multivariate analysis (P0.05).The findings in this study show that even though patients in the M group had a higher degree of mismatch preoperatively and postoperatively, there was no difference in PROMs.Level III.

Propensity score matching (PSM) is a commonly used statistical method in orthopedic surgery research that accomplishes the removal of confounding bias from observational cohorts where the benefit of randomization is not possible. An alternative to multiple regression analysis, PSM attempts to reduce the effects of confounders by matching already treated subjects with control subjects who exhibit a similar propensity for treatment based on preexisting covariates that influence treatment selection. It, therefore, establishes a new control group by discarding outlier control subjects. This new control group reduces the unwanted influences of covariates, allowing for proper measurement of the intended variable. An example from orthopedic spine literature is discussed to illustrate how PSM may be applied in practice. PSM is uniquely valuable in its utility and simplicity, but it is limited in that it requires the removal of data and works primarily on binary treatments. In addition to matching, the propensity score can be used for stratification, covariate adjustments, and inverse probability of treatment weighting, but these topics are outside the scope of this paper. Personnel in the orthopedic field would benefit from learning about the function and application of this method given its common use in the orthopedic literature.

With the rapid rise of clinical spine surgery literature in the last few decades, there is a greater need for practicing spine surgeons to confidently analyze and critique published literature within the field. The conclusions drawn from published studies are often integrated into a physician's clinical decision-making. A strong knowledge in the fundamental statistical measurements used most frequently in spine surgery literature can enhance the ability to properly interpret the meaning of a study's results. However, medical education often lacks the incorporation of clinically relevant statistical analysis. The purpose of this review is to provide an overview of some of the most commonly used statistical measurements in spine surgery, specifically intraclass correlation coefficient, diagnostic testing analyses, Kaplan-Meier curves, hazard ratios, distribution, and variance.

Wearable technology is an exciting industry that has gained exponential traction over the past few years. This technology allows individuals to track personal health and fitness parameters and is becoming more and more precise with modern advancements. As these devices continue to increase in accuracy and gain further utilities in health monitoring, their potential to influence orthopedic care will also grow. Orthopedic surgeons may use this technology to monitor the perioperative course of their patients, who can remotely communicate various parameters related to care without needing to physically be seen by their providers. Wearable devices, while of course promising in the field of medicine, still have limitations that must be overcome before they can widely be adopted into orthopedic care. Our goal is to review current wearables on the market, discuss their potential applications in health care, and postulate their future use in orthopedic care.

Study Design Retrospective case series. Objective To determine risk factors associated with prolonged opioid use after lumbar fusion and to elucidate the effect of opioid use on patient-reported outcome measures (PROMs) after surgery. Methods Patients who underwent 1–3 level lumbar decompression and fusion with at least one-year follow-up were identified. Opioid data were collected through the Pennsylvania Prescription Drug Monitoring Program. Preoperative “chronic use” was defined as consumption of >90 days in the one-year before surgery. Postoperative “prolonged use” was defined as a filled prescription 90-days after surgery. PROMs included the following: Short Form-12 Health Survey PCS-12 and MCS-12, ODI, and VAS-Back and Leg scores. Logistic regression was performed to determine independent predictors for prolonged opioid use. Results The final analysis included 260 patients. BMI >35 (OR: .44 [.20, .90], P = .03) and current smoking status (OR: 2.73 [1.14, 6.96], P = .03) significantly predicted postoperative opioid usage. Chronic opioid use before surgery was associated with greater improvements in MCS-12 (β= 5.26 [1.01, 9.56], P = .02). Patients with prolonged opioid use self-reported worse VAS-Back (3.4 vs 2.1, P = .003) and VAS-Leg (2.6 vs 1.2, P = .03) scores after surgery. Prolonged opioid use was associated with decreased improvement in VAS-Leg over time (β = .14 [.15, 1.85], P = .02). Conclusions Current smoking status and lower BMI were significantly predictive of prolonged opioid use. Excess opioid use before and after surgery significantly affected PROMs after lumbar fusion.

Although patient-reported outcome measures (PROMs) provide valuable insight into the effectiveness of spine surgery, there still remain limitations on measuring outcomes in this manner. Among other deficiencies, PROMs do not always correlate with more objective measures of surgery success. Wearable technology, such as pedometers, tri-axis accelerometer, or wearable cameras, may allow physicians to track patient progress following spine surgery more objectively. Recently, there has been an emphasis on using wearable devices to measure physical activity and limb and spine function. Wearable devices could play an important role as a supplement to PROMs, although they might have to be substantiated through adequate controlled studies to identify normative data for patients presenting with common spine disorders. This review will detail the current state of wearable technology applications in spine surgery and its direction as its utilization expands.

STUDY DESIGN Retrospective comparative study. OBJECTIVE The purpose of this study was to investigate whether preoperative depressive symptoms, measured by mental component score of the Short Form-12 survey (MCS-12), influence patient-reported outcome measurements (PROMs) following an anterior cervical discectomy and fusion (ACDF) surgery for cervical degeneration. SUMMARY OF BACKGROUND DATA There is a paucity of literature regarding preoperative depression and PROMs following ACDF surgery for cervical degenerative disease. METHODS Patients who underwent an ACDF for degenerative cervical pathology were identified. A score of 45.6 on the MCS-12 was used as the threshold for depression symptoms, and patients were divided into two groups based on this value: depression (MCS-12 ≤45.6) and nondepression (MCS-12 >45.6) groups. Outcomes including Neck Disability Index (NDI), physical component score of the Short Form-12 survey (PCS-12), and Visual Analogue Scale Neck (VAS Neck), and Arm (VAS Arm) pain scores were evaluated using independent sample t test, recovery ratios, percentage of patients reaching the minimum clinically important difference, and multiple linear regression - controlling for factors such as age, sex, and BMI. RESULTS The depression group was found to have significantly worse baseline pain and disability than the nondepression group in NDI (P

In July of 2018, the Second International Consensus Meeting (ICM) on Musculoskeletal Infection convened in Philadelphia, PA to discuss issues regarding infection in orthopedic patients and to provide consensus recommendations on these issues to practicing orthopedic surgeons. During this meeting, attending delegates divided into subspecialty groups to discuss topics specifics to their respective fields, which included the spine. At the spine subspecialty group meeting, delegates discussed and voted upon the recommendations for 63 questions regarding the prevention, diagnosis, and treatment of infection in spinal surgery. Of the 63 questions, 11 focused on risk factors and prevention questions in spine surgery, for which this article provides the recommendations, voting results, and rationales.

This was a retrospective comparative study.The goal of this study was to further elucidate the relationship between preoperative depression and patient-reported outcome measurements (PROMs) following lumbar decompression surgery.The impact of preoperative depression on PROMs after lumbar decompression surgery is not well established.Patients undergoing lumbar decompression between 1 and 3 levels were retrospectively identified. Patients were split into 2 groups using a preoperative Mental Component Score (MCS)-12 threshold score of 45.6 or 35.0 to identify those with and without depressive symptoms. In addition, patients were also split based on a pre-existing diagnosis of depression in the medical chart. Absolute PROM scores, the recovery ratio and the percent of patients achieving minimum clinically important difference between groups were compared, and a multiple linear regression analysis was performed.A total of 184 patients were included, with 125 (67.9%) in the MCS-1245.6 group and 59 (32.1%) in the MCS-12 ≤45.6 group. The MCS-12 ≤45.6 and MCS35.0 group had worse baseline Oswestry Disability Index (ODI) (P0.001 for both) and Visual Analogue Scale Leg (P=0.018 and 0.024, respectively) scores. The MCS ≤45.6 group had greater disability postoperatively in terms of SF-12 Physical Component Score (PCS-12) (39.1 vs. 43.1, P=0.015) and ODI (26.6 vs. 17.8, P=0.006). Using regression analysis, having a baseline MCS-12 scores ≤45.6 before surgical intervention was a significant predictor of worse improvement in terms of PCS-12 [β=-4.548 (-7.567 to -1.530), P=0.003] and ODI [β=8.234 (1.433, 15.035), P=0.010] scores than the MCS-1245.6 group.Although all patients showed improved in all PROMs after surgery, those with MCS-12 ≤45.6 showed less improvement in PCS-12 and ODI scores.

In July of 2018, the Second International Consensus Meeting (ICM) on Musculoskeletal Infection convened in Philadelphia, PA was held to discuss issues regarding infection in orthopedic patients and to provide consensus recommendations on these issues to practicing orthopedic surgeons. During this meeting, attending delegates divided into subspecialty groups to discuss topics specifics to their respective fields, which included the spine. At the spine subspecialty group meeting, delegates discussed and voted upon the recommendations for 63 questions regarding the prevention, diagnosis, and treatment of infection in spinal surgery. Of the 63 questions, 9 focused on implants questions in spine surgery, for which this article provides the recommendations, voting results, and rationales.

Introduction The effect of spine fellow versus orthopaedic surgery resident assistance on outcomes in anterior cervical diskectomy and fusion (ACDF) has not been well studied. The objective of this study was to determine differences in patient health-related outcomes based on the level of surgical trainees. Methods Consecutive cases of ACDF (n = 407) were reviewed at a single high-volume institution between 2015 and 2017 and were separated into two groups based on whether they were fellow-assisted or resident-assisted. Demographic and clinical variables were recorded, and health-related quality of life was evaluated using the Short Form-12 (SF-12) survey. The SF-12, visual analog scale pain score, and neck disability index were compared between the two groups. Surgery level, surgical time, preoperative Charlson Comorbidity Index, estimated blood loss, equivalent morphine use, perioperative complications, and 30-day readmission were also recorded. Patient outcomes were compared using an unpaired t-test as well as multivariate linear regression, controlling for age, sex, body mass index, Charlson Comorbidity Index, presurgical visual analog scale, SF-12, and neck disability index. Results were reported with the 95% confidence interval. Results Spine surgery fellows and orthopaedic surgery residents participated in 228 and 179 ACDF cases, respectively. No notable demographic differences between the two groups were found. A higher proportion of three or more level ACDF surgeries assisted by fellows versus residents was found. Estimated blood loss was greater in fellow-assisted ACDF cases. Both surgery time and total time in the room were also longer in the fellow-assisted ACDF group. No 30-day readmissions were found in either groups, and only one case of acute hemorrhagic anemia was found in the fellow-assisted group. Overall, postoperative complications were higher in the resident group; however, no difference with regard to intraoperative complications between groups was found. Discussion This study shows that patient health-related outcomes are similar in ACDF cases that were fellow-assisted versus resident-assisted. However, fellow-assisted ACDF cases were associated with more blood loss and longer surgery time.

STUDY DESIGN A retrospective cohort study. OBJECTIVE The goal of this study was to determine the effect of smoking on patient-reported outcome measurements (PROMs) after lumbar fusion surgery. SUMMARY OF BACKGROUND DATA Although smoking is known to decrease fusion rates after lumbar fusion, there is less evidence regarding the influence of smoking on PROMs after surgery. METHODS Patients undergoing between 1 and 3 levels of lumbar fusion were divided into 3 groups on the basis of preoperative smoking status: never smokers (NS); current smokers (CS); and former smokers (FS). PROMs collected for analysis include the Physical Component Score (PCS-12), Mental Component Score (MCS-12), Oswestry Disability Index (ODI), and Visual Analogue Scale back (VAS back) and leg (VAS leg) pain scores. Preoperative and postoperative PROMs were compared between groups. A multiple linear regression analysis was performed to determine whether preoperative smoking status was a predictor of change in PROM scores. RESULTS A total of 220 (60.1%) NS, 52 (14.2%) CS, and 94 (25.7%) FS patients were included. Patients in most groups improved within each of the PROMs analyzed (P

In July of 2018, the Second International Consensus Meeting on Musculoskeletal Infection convened in Philadelphia, PA to discuss issues regarding infection in orthopedic patients and to provide consensus recommendations on these issues to practicing orthopedic surgeons. During this meeting, attending delegates divided into subspecialty groups to discuss topics specifics to their respective fields, which included the spine. At the spine subspecialty group meeting, delegates discussed and voted upon the recommendations for 63 questions regarding the prevention, diagnosis, and treatment of infection in spinal surgery. Of the 63 questions, 7 focused on wound care, for which this article provides the recommendations, voting results, and rationales.

Shoulder instability encompasses a spectrum of disease ranging from subluxation to dislocation, and is typically associated with collision athletes such as wrestlers and football players. Instability, however, also can be the result of repetitive microtrauma, as seen in overhead athletes (baseball, tennis, volleyball, swimming). The presentation of instability can be subtle, and difficult to diagnose in the absence of an acute traumatic event without the proper suspicion, physical examination, and diagnostic evaluation. Overhead athletes present the unique challenge of requiring the glenohumeral joint to exceed its physiologic limits during competition; therefore, injury in this population can be devastating. Additionally, athletes who experience instability, regardless of treatment, require rehabilitation (including periscapular strengthening) to maximize strength of the surrounding musculature. Specifically they will require coordinated throwing programs, and gradual return to play protocols dependent on their sport. This article reviews the specific physiology, diagnosis, and treatment of shoulder instability in this population.

BACKGROUND CONTEXT Mismatch between pelvic incidence (PI) and lumbar lordosis (LL) has been emphasized as a reason for poor outcomes in deformity surgery and long-segment spinal fusions. However, literature assessing the importance of this spinopelvic relationship on patient outcomes in short segment lumbar fusions for degenerative lumbar disease is scarce. PURPOSE To determine whether patient reported outcomes are affected based on degree of postoperative PI-LL mismatch after 1- and 2-level lumbar fusion for degenerative pathology. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Three hundred and forty-eight patients who underwent a 1-2-level lumbar spine fusion procedure at a high-volume academic center were retrospectively identified. Patients were divided into two groups based on the presence of postoperative PI-LL mismatch ≤ 10° (NM) vs PI-LL mismatch >10° (M). OUTCOME MEASURES Patient reported outcome measures: SF-12 PCS and MCS, ODI, VAS Back, VAS Leg. Spinopelvic measurements: pelvic tilt (PT), sacral slope (SS), pelvic incidence (PI), lumbar lordosis (LL). METHODS Preoperative and postoperative radiographic measurements were obtained for all patients. Those with less than one-year follow-up were excluded. Univariate analysis with an independent t-test or Mann-Whitney U test was used to compare differences between groups. Multiple linear regression was used to determine if postoperative PI-LL mismatch was an independent predictor of change in each patient outcome. RESULTS Sixty-seven patients were included in the NM group compared to 281 patients in the M group. There were no baseline differences (p > 0.05) in age, sex, BMI, CCI, smoking status, follow-up, preoperative diagnosis, number of levels decompressed and fused, or number of cases with TLIF or ALIF. On univariate analysis, there was a significant difference pre- and postoperatively in PT, PI, LL and PI-LL between the two groups at baseline and postoperatively (p 0.05). In addition, having a postoperative PI-LL mismatch was not found to be an independent predictor of any health-related outcome score on multiple linear regression analysis. CONCLUSIONS Pelvic incidence minus lumbar lordosis is recognized as an important spinopelvic parameter to normalize in deformity surgery; however, this importance is less clear in short-segment lumbar fusion for degenerative pathology. The results of this study show that even though the M group had a higher degree of mismatch pre- and postoperatively, there was no difference in patient-reported outcomes before or after surgery. This is one of the first studies to report on short-term patient outcomes based on spinopelvic parameters in routine lumbar degenerative cases. Further research is needed to elucidate this important relationship. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Instrumentation for surgery can be a significant contributor to high costs associated with spine procedures. Traditional, reusable instruments require sterilization and reprocessing for their next surgery, whereas single-use systems offer the advantage of avoiding those steps. However, little is currently known regarding the difference in time and resources between these two systems. PURPOSE To compare the instrumentation-related cost of single-use vs reusable instrument trays. STUDY DESIGN/SETTING Prospective cohort study. PATIENT SAMPLE Patients undergoing lumbar decompression and single-level fusion surgeries were prospectively enrolled at a large academic hospital between July 2017–October 2018. Twenty patients were enrolled in the single-use instrumentation group vs 20 patients in the reusable instrumentation group. OUTCOME MEASURES Time spent handling instruments per case, total cost of instrumentation per case. METHODS A single observer recorded the total time spent for instrument handling, opening, setup and restocking by direct observation and using a hand-held stopwatch. The variable per-case cost associated with reusable instrumentation was calculated as: Costresuable = CostOR +CostSPD, where CostOR is the number of hours instruments that were handled multiplied by the OR nurse hourly salary and CostSPD is the cost of reprocessing an instrumentation tray in the sterile processing department (SPD). Single-use instrumentation did not require reprocessing, so the variable Costsingle-use = CostOR. Independent samples t-tests or Chi-squared/Fisher's exact tests were used to determine differences for continuous and categorical data, respectively. RESULTS There were no significant baseline differences between groups (p >0.05). The mean time from opening of instrumentation to use was 158.4±48.5 minutes for the reusable group compared to 40±6.5 min (p =0.0008) for the single-use group. The mean time of handling reusable instruments by the OR nurse was 11.6±3.9 minutes, compared to 2.1±0.5 minutes for single-use instruments (p CONCLUSIONS In this study, single-use instrumentation provided significantly greater cost savings when compared to reusable instrumentation that is independent of the cost of the instrumentation. Additionally, there was significantly reduced time from the opening of instrumentation to use in surgery for the single-use system, potentially limiting contamination in the surgical field. Further prospective studies are needed to explore this relationship. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

In July 2018, the Second International Consensus Meeting on Musculoskeletal Infection convened in Philadelphia, PA to discuss issues regarding infection in orthopedic patients and to provide consensus recommendations on these issues to practicing orthopedic surgeons. During this meeting, attending delegates divided into subspecialty groups to discuss topics specifics to their respective fields, which included the spine. At the spine subspecialty group meeting, delegates discussed and voted upon the recommendations for 63 questions regarding the prevention, diagnosis, and treatment of infection in spinal surgery. Of the 63 questions, 15 focused on the use of imaging, tissue sampling, and biomarkers in spine surgery, for which this article provides the recommendations, voting results, and rationales.

BACKGROUND CONTEXT Lumbar decompression and fusion surgery is a common orthopedic procedure and a key component in surgical training for both orthopedic spine surgery fellows and orthopedic surgery residents. While the impact of trainee involvement in other fields is well established, there is a paucity of literature assessing this relationship in spine surgery. PURPOSE To determine whether the presence of a fellow or resident (F/R) compared to a physician assistant (PA) affected surgical characteristics or short-term patient outcomes. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Three hundred and fifty patients who underwent a 1-3 level lumbar spine fusion with 1-5 levels of decompression at a high-volume academic center were retrospectively identified. Patients were divided into two groups based on whether an orthopedic spine fellow or resident was involved in the surgical case compared to a physician assistant. OUTCOME MEASURES Total surgery duration, length of stay, 30-day and 90-day readmissions, infection and revision rates, patient-reported outcome measures (SF-12 PCS and MCS, ODI, VAS Back, VAS Leg). METHODS Operative reports from all cases were examined and patients were placed into the F/R or PA group based on whether a trainee or PA was assisting the attending surgeon. Patients with less than one-year follow-up were excluded. Univariate analysis was used to compare differences between groups. Multiple linear regression was used to assess change in each patient reported outcome and multiple binary logistic regression was used to determine significant predictors of revision, infection, and 30- or 90-day readmission. RESULTS One hundred and seventy-two patients were included in the F/R group compared to 178 patients in the PA group. There were no baseline differences in age, sex, BMI, smoking status, follow-up, preoperative diagnosis, number of levels decompressed and fused, or surgery type. Patients in the F/R group had a significantly higher age-adjusted Charlson Comorbidity Index (aCCI), 3.40 [3.07, 3.74] vs. 2.69 [2.39, 3.00], p = 0.002. There were no differences between groups for total surgery time, length of stay, 30-day or 90-day readmissions, infection or revision rates. On univariate analysis of patient-reported outcomes, there were no differences between groups pre- or postoperatively. Using multiple linear regression analysis, presence of a surgical trainee did not significantly influence any patient reported outcome. Multiple logistic regression analysis also showed that presence of a surgical trainee did not affect infection, revision, or 30- and 90-day readmission rates. CONCLUSIONS Despite operating on patients with significantly more comorbidities, the results of this study show that the presence of an orthopedic spine fellow or orthopedic surgery resident does not increase complication rates and does not affect short-term patient-reported outcomes in lumbar decompression and fusion surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Magnetic resonance imaging (MRI) is routinely obtained for patients with lumbar disc herniations. However, the correlation between radiographic findings and the timing of patient symptoms is still controversial. PURPOSE To determine whether the MRI signal characteristics at the level of disc herniation are predictive of acuity or chronicity of symptoms. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Ninety-four patients treated at a high-volume academic center for a lumbar disc herniation between January 2015 and August 2018 were retrospectively identified. Patients were divided into two groups based on symptom duration (acute, less than or equal to 6 months, or chronic, greater than 6 months). OUTCOME MEASURES Disc height, central T2 signal, herniation T2 signal, central T1 signal, herniation T1 signal, Pfirrmann Grade, nerve root compression, Modic changes, facet degeneration, vertebral body spurring, and ligamentum flavum hypertrophy. METHODS MRIs for patients in both groups were reviewed and radiographic characteristics measured. T1/2 central signal and herniation signals were determined from the central 80% and the peripheral 20%, respectively. All variables were recorded as either normal or abnormal, except for Pfirrmann grade, Modic changes, and vertebral body spurring. Univariate analysis was used to compare differences between nonoperative and operative groups. Multiple binary logistic regression was used to determine significant predictors of chronicity, controlling for age, sex, and disc herniation level. RESULTS There were no significant baseline differences on univariate analysis. Time to surgery in the acute and chronic groups was 2.30 [1.28, 3.33] vs 2.33 [1.39, 3.26] months, respectively (p = 0.826). There were no significant differences in disc height, T2/T1 central, and T2/T1 herniation signal characteristics between the two groups (p > 0.05). There was a significant difference in Pfirrmann grade, with the chronic group having a higher proportion of grade 5 (37.0% vs 8.3%, p=0.007). Presence of vertebral body spurring was also significantly different between groups, with the chronic group having a higher proportion of posterior marginal and anterior/posterior spurring (p = 0.006). Multiple logistic regression analysis showed lower odds of predicting acute disc herniation with Pfirrmann grade 5 (OR 0.12 [0.02, 0.74], p = 0.022) or the presence of anterior/posterior spurring (OR 0.053 [0.02, 0.74], p = 0.023). CONCLUSIONS This is one of the first studies to assess acuity of symptoms and MRI signal characteristics. Outside of advanced degenerative findings such as Pfirrmann grade 5 or anterior and posterior vertebral body spurring, no other MRI characteristics could be identified that correlate with acuity of symptoms. Therefore, close clinical correlation is important in combination with imaging in treating patients with lumbar disc herniation. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.