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Study Design: Retrospective case-control study., Objective: The aim of this study was to determine the influence of obesity on risk factors for adverse outcome after lumbar spine fusion (LSF)., Summary of Background Data: Obesity is risk factor for complications after LSF and poses unique challenges regarding optimization of care. Nonetheless, this patient population is not well-studied., Methods: Adult patients undergoing LSF were identified the State Inpatient Database. Patients were identified as obese or nonobese using ICD-9 codes. Outcome variables were 90-day readmission, major medical complication, infection, and revision rates. Data were queried for demographics, comorbidities, surgery characteristics, and outcome variables. Logistic multivariate regression was utilized, serially testing interactions between obesity and other independent variables in separate models for each outcome. The Benjamini-Hochberg procedure was used to adjust statistical significance for multiple comparisons., Results: A total of 262,153 patients were included: 31,062 obese and 231, 091 nonobese. For major complications, obese patients had lower odds ratios (ORs) versus nonobese patients for cerebrovascular accident, diabetes with chronic complications, age ≥65, congestive heart failure, history of myocardial infarction, renal disease, chronic pulmonary disease, Medicare/Medicaid payor, more than two levels fused, transforaminal/posterior lumbar interbody fusion, and female sex, and higher OR for non-White race. For readmission, obese patients had lower OR for age ≥65, history of MI, renal disease, and mental health disease, and higher OR for female sex. For revision, obese patients had higher OR for female sex and TLIF/PLIF. For infection, obese patients had lower OR for diabetes with and without chronic complications, and higher OR for female sex., Conclusion: Many medical comorbidities have less impact in obese patients than nonobese patients in predicting adverse outcomes despite increased rates of adverse outcomes in obese patients. These findings reflect the impact of obesity as an independent risk factor and have important implications for preoperative optimization.Level of Evidence: 3., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Anterior lumbar interbody fusion (ALIF) is a powerful technique that provides wide access to the disc space and allows for large lordotic grafts. When used with posterior spinal fusion (PSF), the procedures are often staged within the same hospital admission. There are limited data on the perioperative risk profile of ALIF-first versus PSF-first circumferential fusions performed within the same hospital admission. In an effort to understand whether these procedures are associated with different perioperative complication profiles, the authors performed a retrospective review of their institutional experience in adult patients who had undergone circumferential lumbar fusions., Methods: The electronic medicals records of patients who had undergone ALIF and PSF on separate days within the same hospital admission at a single academic center were retrospectively analyzed. Patients carrying a diagnosis of tumor, infection, or traumatic fracture were excluded. Demographics, surgical characteristics, and perioperative complications were collected and assessed., Results: A total of 373 patients, 217 of them women (58.2%), met the inclusion criteria. The mean age of the study cohort was 60 years. Surgical indications were as follows: degenerative disease or spondylolisthesis, 171 (45.8%); adult deformity, 168 (45.0%); and pseudarthrosis, 34 (9.1%). The majority of patients underwent ALIF first (321 [86.1%]) with a mean time of 2.5 days between stages. The mean number of levels fused was 2.1 for ALIF and 6.8 for PSF. In a comparison of ALIF-first to PSF-first cases, there were no major differences in demographics or surgical characteristics. Rates of intraoperative complications including venous injury were not significantly different between the two groups. The rates of postoperative ileus (11.8% vs 5.8%, p = 0.194) and ALIF-related wound complications (9.0% vs 3.8%, p = 0.283) were slightly higher in the ALIF-first group, although the differences did not reach statistical significance. Rates of other perioperative complications were no different., Conclusions: In patients undergoing staged circumferential fusion with ALIF and PSF, there was no statistically significant difference in the rate of perioperative complications when comparing ALIF-first to PSF-first surgeries.

Study Design: Retrospective case control study., Objective: To develop predictive models for postoperative outcomes after long segment lumbar posterior spine fusion (LSLPSF)., Summary of Background Data: Surgery for adult spinal deformity is effective for treating spine-related disability; however, it has high complication and readmission rates., Methods: Patients who underwent LSLPSF (three or more levels) were identified in State Inpatient Database. Data was queried for discharge-to-facility (DTF), 90-day readmission, and 90-day major medical complications, and demographic, comorbid, and surgical data. Data was partitioned into training and testing sets. Multivariate logistic regression, random forest, and elastic net regression were performed on the training set. Models were applied to the testing set to generate AUCs. AUCs between models were compared using the method by DeLong et al. RESULTS.: 37,852 patients were analyzed. The DTF, 90-day readmission, and 90-day major medical complication rates were 35.4%, 19.0%, and 13.0% respectively. For DTF, the logistic regression AUC was 0.77 versus 0.75 for random forest and 0.76 for elastic net (P < 0.05 for all comparisons). For 90-day readmission, the logistic regression AUC was 0.65, versus 0.63 for both random forest and elastic net (P < 0.05 for all comparisons). For 90-day major medical complications, the logistic regression AUC was 0.70, versus 0.69 for random forest and 0.68 for elastic net (P < 0.05 for all comparisons)., Conclusion: This study created comprehensive models to predict discharge to facility, 90-day readmissions, and 90-day major medical complications after LSLPSF. This information can be used to guide decision making between the surgeon and patient, as well as inform value-based payment models., Level of Evidence: 3.

Background: Asymmetric pedicle subtraction osteotomy (APSO) can be utilized for adult spinal deformity (ASD) with fixed coronal plane imbalance. There are few reports investigating outcomes following APSO and no series that include multiple revision cases., Objective: To detail our surgical technique and experience with APSO., Methods: All thoracolumbar ASD cases with a component of fixed, coronal plane deformity who underwent APSO from 2004 to 2016 at one institution were retrospectively reviewed. Preoperative and latest follow-up radiographic parameters and data on surgical outcomes and complications were obtained., Results: Fourteen patients underwent APSO with mean follow-up of 37-mo. Ten (71.4%) were revision cases. APSO involved a mean 12-levels (range 7-25) and were associated with 3.0 L blood loss (range 1.2-4.5) and 457-min of operative time (range 283-540). Surgical complications were observed in 64.3%, including durotomy (35.7%), pleural injury (14.3%), persistent neurologic deficit (14.3%), rod fracture (7.1%), and painful iliac bolt requiring removal (7.1%). Medical complications were observed in 14.3%, comprising urosepsis and 2 cases of pneumonia. Two 90-d readmissions (14.3%) and 5 reoperations (4 patients, 28.6%) occurred. Mean thoracolumbar curve and coronal vertical axis improved from 31.5 to 16.4 degrees and 7.8 to 2.9 cm, respectively. PI-LL mismatch, mean sagittal vertical axis, and pelvic tilt improved from 40.0 to 27.9-degrees, 10.7 to 3.5-cm, and 34.4 to 28.3-degrees, respectively., Conclusion: The APSO, in both a revision and non-revision ASD population, provides excellent restoration of coronal balance-in addition to sagittal and pelvic parameters. Employment of APSO must be balanced with the associated surgical complication rate (64.3%)., (Copyright © 2019 by the Congress of Neurological Surgeons.)

MINI: Proximal junctional kyphosis (PJK) is a common, yet incompletely understood, complication of surgery for adult spinal deformity. We analyzed 440 consecutive adult spinal deformity patients for trends in development of PJK and need for revision surgery. pelvic tilt and thoracic kyphosis were predictive for developing PJK, while radiographic evidence of proximal junctional failure was predictive for proceeding to revision., Study Design: Retrospective review of prospectively collected data., Objective: The aim of this study was to examine which radiographic parameters and surgical strategies are most closely associated with proximal junctional kyphosis (PJK) after adult spinal deformity (ASD) surgery, the need for revision surgery for PJK, and whether these differ based on the upper instrumented vertebra (UIV)., Summary of Background Data: Multiple parameters are considered when planning correction of ASD. Determining which of these factors contribute to the development of and need for revision surgery for PJK presents a challenging problem., Methods: Consecutive patients undergoing long fusion to the pelvis with age >18 years, minimum 6-month follow-up, and adequate radiographs for analysis in a single institution between 2003 and 2011 were included. Along with chart review, measurement of proximal junctional angle (PJA), sagittal balance, and pelvic parameters was performed on preoperative, postoperative, and latest follow-up radiographs. Postoperative radiographs were also examined for signs of PJF., Results: A total of 440 patients with a mean follow-up of 34 months met inclusion criteria, 159 of whom developed PJK (36%), with 65 requiring revision surgery (41%). Higher preoperative pelvic tilt (PT) (P = 0.018) and postoperative thoracic kyphosis (TK) (P ≤ 0.001) were predictive for development of PJK, whereas hooks at UIV were protective (odds ratio [OR] 0.049). In patients who developed PJK, revision was more frequent in younger patients (P = 0.005) with greater postoperative sagittal vertical axis and PJA (P = 0.029, P = 0.018). PJF with spondylolisthesis, fracture, or instrumentation failure at the UIV had the highest ORs for proceeding to a revision (5.1, 1.6, and 2.2, respectively)., Conclusion: TK and PT are important indicators of overall rigidity and reference the ability of the spine to compensate for sagittal plane deformity. Special attention should be paid to these characteristics and to the choice of proximal instrumentation when attempting to prevent PJK. Prevention of radiographically evident PJF may hold the key to reducing the need for revision surgery., Level of Evidence: 3.

Background: Postoperative pain and opioid use are associated with postoperative delirium. We designed a single-center, randomized, placebo-controlled, parallel-arm, double-blinded trial to determine whether perioperative administration of gabapentin reduced postoperative delirium after noncardiac surgery., Methods: Patients were randomly assigned to receive placebo (N = 347) or gabapentin 900 mg (N = 350) administered preoperatively and for the first 3 postoperative days. The primary outcome was postoperative delirium as measured by the Confusion Assessment Method. Secondary outcomes were postoperative pain, opioid use, and length of hospital stay., Results: Data for 697 patients were included, with a mean ± SD age of 72 ± 6 yr. The overall incidence of postoperative delirium in any of the first 3 days was 22.4% (24.0% in the gabapentin and 20.8% in the placebo groups; the difference was 3.20%; 95% CI, 3.22% to 9.72%; P = 0.30). The incidence of delirium did not differ between the two groups when stratified by surgery type, anesthesia type, or preoperative risk status. Gabapentin was shown to be opioid sparing, with lower doses for the intervention group versus the control group. For example, the morphine equivalents for the gabapentin-treated group, median 6.7 mg (25th, 75th quartiles: 1.3, 20.0 mg), versus control group, median 6.7 mg (25th, 75th quartiles: 2.7, 24.8 mg), differed on the first postoperative day (P = 0.04)., Conclusions: Although postoperative opioid use was reduced, perioperative administration of gabapentin did not result in a reduction of postoperative delirium or hospital length of stay.

Background Context: Surgical treatment for adult spinal deformity improves patient quality of life; however, trends in surgical utilization in the elderly, who may be at higher risk for complications, remain unclear., Purpose: To identify trends in the utilization of adult deformity and determine complication rates among older patients., Study Design: This is a retrospective database analysis., Patient Sample: The Nationwide Inpatient Sample database was queried from 2004 to 2011 to identify adult patients who underwent spinal fusion of eight or more levels using International Classification of Diseases, Ninth Revision (ICD-9) coding., Outcome Measures: Incidence of surgery, complication rates, length of stay, and total hospital charges., Methods: The incidence of surgery was normalized to United States census data by age group. Trends in complications, length of stay, and inflation-adjusted hospital charges were determined using linear regression and Cochran-Armitage trend testing., Results: An estimated 29,237 patients underwent adult spinal deformity surgery with an increase from 2,137 to 5,030 cases per year from 2004 to 2011. Surgical incidence among patients 60 years and older increased from 1.9 to 6.5 cases per 100,000 people from 2004 to 2011 (p<.001), whereas utilization in patients younger than 60 increased from 0.59 to 0.93. Linear regression revealed that the largest increase in surgical utilization was for patients aged 65-69 years with an increase of 0.68 patients per 100,000 people per year (p<.001), followed by patients aged 70-74 years with a rate of 0.56 patients per 100,000 people per year (p=.001). Overall complication rates were 22.5% in 2004 and 26.7% in 2011. Although complication risk increased with age (≥60 vs. <60: relative risk 1.91 [1.83, 1.99], p<.001), within-age group rates were stable over time. Mean length of stay was 9.6 days in 2004 and 9.0 days in 2011. Inflation-adjusted mean hospital charges increased from $171,517 in 2004 to $303,479 in 2011 (p<.001)., Conclusions: Operative management of adult spinal deformity increased 3.4-fold among patients ≥60 years from 2004 to 2011, with an associated 1.8-fold increase in hospital charges. Although the exact reasons for the striking increase in hospital charges remain unclear, some of the increase is likely related to decreasing reimbursement of charges by payors over the same period of time. The large majority of cases were performed in large academic centers, and growth in deformity trained spine specialists in these centers may have contributed to this trend. Despite the increased utilization of surgery for adult spinal deformity, in-hospital complications remained stable across all ages., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: A potential long-term complication of lumbar fusion is the development of adjacent segment disease (ASD), which may necessitate second surgery and adversely affect outcomes. The objective of this is to determine the incidence of ASD following instrumented fusion in adult patients with lumbar spondylolisthesis and to identify the risk factors for this complication., Patients and Methods: We retrospectively assessed adult patients who had undergone decompression and instrumented fusion for lumbar spondylolisthesis between January 2006 and December 2012. The incidence of ASD was analyzed. Potential risk factors included the patient-related factors, surgery-related factors, and radiographic variables such as sagittal alignment, preexisting disc degeneration and spinal stenosis at the adjacent segment., Results: A total of 154 patients (mean age, 58.4 years) were included. Mean duration of follow-up was 28.6 months. Eighteen patients (11.7%) underwent a reoperation for ASD; 15 patients had reoperation at cranial ASD and 3 at caudal ASD. The simultaneous decompression at adjacent segment (p=0.002) and preexisting spinal stenosis at cranial adjacent segment (p=0.01) were identified as risk factors for ASD. The occurrence of ASD was not affected by patient-related factors, the types, grades and levels of spondylolisthesis, surgical approach, fusion procedures, levels of fusion, number of levels fused, types of bone graft, use of bone morphogenetic proteins, sagittal alignment, preexisting adjacent disc degeneration and preexisting spinal stenosis at caudal adjacent segments., Conclusion: Our findings suggest the overall incidence of ASD is 11.7% in adult patients with lumbar spondylolisthesis after decompression and instrumented fusion at a mean follow-up of 28.6 months, the simultaneous decompression at the adjacent segment and preexisting spinal stenosis at cranial adjacent segment are risk factors for ASD., (Copyright © 2017. Published by Elsevier B.V.)

Sexual function (SF) is an important component of patient-focused health related quality of life (HRQoL), but it has not been well studied in spine surgery. This study aims to assess SF after cervical spine surgery and identify predictors of SF. This single-center retrospective study evaluates SF of adults who underwent cervical spine surgery 2007-2012. Predictor variables included demographics, medical/surgical history, operative information, HRQoL measures (Neck Disability Index, SF-12), validated SF surveys [Female Sexual Function Index (FSFI) and Brief Sexual Function Inventory (BSFI) for males], and a study-specific SF questionnaire. 59 patients (31M, 28F; mean age=56±8.4) had significantly lower SF scores compared to age-matched peers: average BSFI = 2.26±1.22 (vs. 06±0.74), average FSFI=13.05±11.42 (<26.55 indicating sexual dysfunction). In men, lower mental SF-12 and higher NDI, back pain, and number of operated levels were associated with lower BSFI scores (all p<0.05). In women, higher total number of medications and pain medications were associated with lower FSFI scores (both p<0.05). 46% of patients reported difficulty performing a sexual position after surgery that they had previously enjoyed. 39% of men had difficulty on top during intercourse, and 32% of participants reported difficulty performing oral sex. 39% of patients reported worse SF, while only 5% reported an improvement in postoperative SF. Men and women who underwent cervical spine surgery had lower SF scores than age-matched peers, likely attributable to general mental health, regional neck disability, back pain, and medications. A large portion of patients reported subjectively worsened SF after surgery., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Study Design: Retrospective cohort analysis., Objective: To evaluate the economic impact of revision surgery for proximal junctional failures (PJF) after thoracolumbar fusions for adult spinal deformity (ASD)., Summary of Background Data: PJF after fusions for ASD is a major cause of disability. Although clinical sequelae are described, PJF-revision operation costs are incompletely defined., Methods: Consecutive adults who underwent thoracolumbar fusions for ASD (August, 2003 to January, 2013) were evaluated. Inclusion criteria include construct from pelvis to L2 or above and minimum 6 months follow-up after the index ASD operation. Direct costs (surgical supplies/implants, room/care, pharmacy, services) were identified from medical billing data and calculated for index ASD operations and subsequent surgeries for PJF. Not included in direct cost data were indirect costs, charges, surgeon fees, or revision operations for indications other than PJF (i.e., pseudarthrosis). Patients were compared based on the construct's upper-instrumented vertebra: upper thoracic (UT: T1-6) versus thoracolumbar junction (TLjxn: T9-L2)., Results: Of 501 patients, 382 met inclusion criteria. Fifty-one patients [UT:14; TLjxn: 40 at index; average follow-up 32.6 months (6-92 months)] had revisions for PJF, which summed to $3.2 million total direct cost. Average direct cost of index operations for the cohort ($68,294) was significantly greater than PJF-revisions ($55,547). Compared with TLjxn, UT had a significantly higher average cost for index operations ($79,860 vs. $65,868). However, PJF-revision cases were similar in average cost (UT:$60,103; TLjxn:$53,920; P = 0.09). Costs of PJF amounted to an additional 12.1% of the total index surgical cost in 382 patients., Conclusion: Revision operations for PJF after long thoracolumbar fusions for ASD are associated with an average direct cost of $55,547 per case. Revision costs for PJF are similar based on the index procedure's upper-instrumented vertebra level. At a major tertiary center over a 10-year period, PJF came at a very significant economic expense amounting to $3.2 million for 57 cases., Level of Evidence: 3.

Study Design: Retrospective cohort analysis of risk factors in revision spine surgery using a prospectively collected database., Objective: To examine the risk of developing early (30-day) complications across obesity level after adjusting for comorbidities in patients undergoing revision spine surgery., Summary of Background Data: Prior studies suggest obesity influences early complications after primary surgery. The association between obesity and early complications after revision surgery remains to be characterized., Methods: Data were abstracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2012. Adult Caucasian patients undergoing removal/revision of instrumentation or exploration of fusion were included. Patients were categorized by WHO body mass index (BMI, kg/m): Non-Obese (18.5-29.9), Obese Class I (30-34.9), and Obese Class II/III (≥35). Univariate regression was performed to assess the predictive value of obesity level and baseline risk factors in the presence of at least one early complication, and significant predictors were entered into the multivariable model., Results: Of 2538 patients, 57.6% were nonobese, 23% Obese Class I, and 19.4% Obese Class II/III. Obesity was associated with diabetes, hypertension, respiratory disease, and American Society of Anesthesiologists (ASA) score of 3-4 (all P < 0.001). BMI group (P = 0.01), older age (P = 0.008), functional dependence (P < 0.001), ASA 3-4 (P = 0.008), bleeding disorder (P = 0.04), and diabetes (P = 0.016) were identified as univariate predictors for early complications. In the multivariable model, higher BMI (P = 0.04), older age (P = 0.014), and functional dependence (P < 0.001) remained significant predictors for early complications. Notably, patients who were Obese Class II/III (OR 1.66, 95% CI [1.12-2.45]), age ≥75 (OR 1.83, [1.20-2.81]), and functionally dependent (OR 3.02 [1.85-4.94]) had significantly higher risk compared with their reference groups., Conclusion: Obesity is an independent risk factor for early complications after revision spine surgery. Although obesity may not contraindicate revision surgery, its status as a modifiable risk factor warrants disclosure and preoperative counseling to optimize outcomes., Level of Evidence: 3.

Study Design: Retrospective cohort analysis., Objective: To evaluate efficacy of proximal junction fracture (PJF) prevention in adult spinal deformity (ASD) using 2-level cement augmentation at the construct's proximal extent., Summary of Background Data: Prevention of PJF after thoracolumbar fusions is critical because they may result in neurological injury. Cement augmentation of constructs' proximal vertebrae is postulated to decrease PJF., Methods: Patients with ASD after PSF from pelvis to thoracolumbar junction with 6 months or more follow-up were retrospectively studied. Demographics, deformity radiographical parameters, and health-related quality of life outcomes (HRQoL) scores were compared with patients with no cement, 2-level cement augmentation at upper instrumented vertebra (UIV) and vertebra 1 level proximal to UIV (UIV+1), and cement at another location ("Other"). Revision surgery for PJF was primary outcome. Univariable and multivariable logistic regression analyses were used for statistical analysis., Results: 51 patients [female-29; male-22; average age: 65 yr (33-82)] met inclusion criteria (2-level-19; no-cement-23; "Other"-9). Average follow-up (mo) was longer for no-cement (25 ± 15) and "Other" (20 ± 16) than 2-level (15 ± 8) (P = 0.06). All perioperative radiographical parameters were similar, save first postoperative thoracic kyphosis and lumbopelvic mismatch. Compared with 2-level cement, non-2-level cement had significantly more revisions for PJF (0% vs. 19%; P = 0.02). After UIV adjustment, risks of PJF revision surgery were 13.1 times higher for "Other" (95% CI: 0.5-346.5, P = 0.12) and 9.2 times higher (95% CI: 0.4-239.1, P = 0.18) for no-cement. All HRQoL scores improved in 2-level cement; only back/leg pain significantly improved in non-2-level cement. Postoperative Oswestry Disability Index was significantly less in 2-level cement., Conclusion: The use of 2-level cement augmentation (UIV and UIV+1) in PSF from pelvis to thoracolumbar junction for ASD is associated with a decreased rate of acute proximal junctional fractures and associated revision surgeries. As only associations can be demonstrated from this study's design, prospective investigations with larger, consecutive cohorts should be performed to explore causal relationships., Level of Evidence: 3.

Study Design: Retrospective cohort study., Objective: This study aimed to identify the rates and causes of unplanned hospital readmission at 30 days and 1 year after surgical treatment of primary and metastatic spinal tumors., Summary of Background Data: Primary spine tumors and non-spine tumors metastatic to the spine can represent complex problems for surgical treatment, but surgical intervention can provide significant patients with significant improvements in quality of life. However, recent emphasis on decreasing the cost of health care has led to a focus on quality measures such as hospital readmission rates., Methods: At a large referral spine center between 2005 and 2011, 197 patients with primary (n = 33) or metastatic (n = 164) tumors of the spine were enrolled. Hospital readmissions within 1 year were reviewed. Kaplan-Meier analysis was performed to estimate unplanned hospital readmission rates, and risk factors were evaluated using a Cox proportional hazards model., Results: Unplanned hospital readmission rates were 6.1% and 16.8% at 30 days for primary and metastatic tumors (P = 0.126), respectively, and 27.5% and 37.8% at 1 year (P = 0.262). Metastatic tumors with aggressive biology (i.e., lung, osteosarcoma, stomach, bladder, esophagus, pancreas) caused higher rates of readmission than other types of metastatic tumors. One-third of readmissions were due to recurrent disease, whereas 23.3% were due to surgical complications and 43.3% due to medical complications. Numerous medical comorbidities increased the risk of unplanned hospital readmission., Conclusion: Unplanned hospital readmissions after surgical intervention for spine tumors are common, and patients with aggressive metastatic tumors are at increased risk. In addition, comorbid medical problems are important risk factors that increase the chance that a patient will require hospital readmission within 1 year., Level of Evidence: 3.

Object: Proximal junctional kyphosis (PJK) is a common and significant complication after corrective spinal deformity surgery. The object of this study was to compare-based on clinical outcomes, postoperative proximal junctional kyphosis rates, and prevalence of revision surgery-proximal thoracic (PT) and distal thoracic (DT) upper instrumented vertebra (UIV) in adults who underwent spine fusion to the sacrum for the treatment of spinal deformity., Methods: In this retrospective study the authors evaluated clinical and radiographic data from consecutive adults (age > 21 years) with a deformity treated using long instrumented posterior spinal fusion to the sacrum in the period from 2007 to 2009. The PT group included patients in whom the UIV was between T-2 and T-5, whereas the DT group included patients in whom the UIV level was between T-9 and L-1. Perioperative surgical data were compared between the PT and DT groups. Additionally, segmental, regional, and global spinal alignments, as well as the sagittal Cobb angle at the proximal junction, were analyzed on preoperative, early postoperative, and final standing 36-in. radiographs. Patient-reported outcome measurements (visual analog scale, Scoliosis Research Society Patient Questionnaire-22, Oswestry Disability Index, and the 36-Item Short-Form Health Survey) were compared., Results: Eighty-nine patients, 22 males and 67 females, had a minimum follow-up of 2 years, and thus were eligible for participation in this study. Sixty-seven patients were in the DT group and 22 were in the PT group. Operative time (p = 0.387) and estimated blood loss (p < 0.05) were slightly higher in the PT group. The overall rate of revision surgery was 48.0% and 54.5% in the DT and PT groups, respectively (p = 0.629). The prevalence of PJK according to radiological criteria was 34% in the DT group and 27% in the PT group (p = 0.609). The percent of patients with PJK that required surgical correction (surgical PJK) was 11.9% (8 of 67) in the DT group and 9.1% (2 of 22) in the PT group (p = 1.0). The onset of surgical PJK was significantly earlier than radiological PJK in the DT group (p < 0.01). The types of PJK were different in the PT and DT groups. Compression fracture at the UIV was more prevalent in the DT group, whereas subluxation was more prevalent in the PT group. Postoperatively, the PT group had less thoracic kyphosis (p = 0.02), less sagittal imbalance (p < 0.01), and less pelvic tilt (p = 0.04). In the DT group, early postoperative radiographs demonstrated that the proximal junctional angle of patients with surgical PJK was greater than in those without PJK and those with radiological PJK (p < 0.01). Clinical outcomes were significantly improved in both groups, and there was no significant difference between the groups., Conclusions: Both PT and DT UIVs improve segmental and global sagittal plane alignment as well as patient-reported quality of life in those treated for adult spinal deformity. The prevalence of PJK was not different in the PT and DT groups. However, compression fracture was the mechanism more frequently observed with DT PJK, and subluxation was the mechanism more frequently observed in PT PJK. Strategies to avoid PJK may include vertebral augmentation to prevent fracture at the DT spine and mechanical means to prevent vertebral subluxation at the PT spine.

Study Design: Retrospective cohort study., Objective: To assess the rate, causes, and risk factors of unplanned hospital readmission after spine fusion for the treatment of adult spinal deformity., Summary of Background Data: Hospital readmissions in the elderly are common, and with increasing emphasis on the quality of health care, readmission rates are used to assess hospital performance. Spine surgery has seen rapidly increased utilization during the past 2 decades. Surgical treatments of complex spinal deformity are known to have higher rates of complications than other types of spine surgery. However, there are no reports describing the rates and causes of hospital readmission after deformity surgery., Methods: Patients were identified at a single institution from 2006 through 2011 that received a spine fusion for the treatment of adult spinal deformity. All hospital readmissions within 90 days of discharge were reviewed for cause. Unplanned readmission rates were calculated via Kaplan-Meier failure analysis. Rates were compared across patients receiving different lengths of spine fusion (short: 2-3 vertebra, medium: 4-8, long: 9 or more). Risk factors were assessed using a Cox proportional hazards multivariate model., Results: Eight hundred thirty-six patients were enrolled (111 short, 402 medium, and 323 long fusions). The overall unplanned readmission rate was 8.4% at 30 days and 12.3% at 90 days. Patients with long spine fusion had higher rates of readmission than patients with medium or short length fusions. Surgical site infection accounted for 45.6% of readmissions. Risk factors for readmission include longer fusion length, higher patient severity of illness, and specific medical comorbidities., Conclusion: Unplanned hospital readmissions after spine fusion for adult spinal deformity are common, and are most often due to surgical site infection. Patient medical comorbidities are an important part of assessing risk and can be used by providers and patients to better assess individual risk prior to treatment.

Study Design: Retrospective analysis., Objective: The objective of this study was to investigate the accuracy of using an automated approach to administrative claims data to assess the rate and risk factors for surgical site infection (SSI) in spinal procedures., Summary of Background Data: SSI is a major indicator of health care quality. A wide range of SSI rates have been proposed in the literature depending on clinical setting and procedure type., Methods: All spinal surgeries performed at a university-affiliated tertiary-care center from July 2005 to December 2010 were identified using diagnosis-related group, current procedural terminology, and International Classification of Diseases, Ninth Revision (ICD-9) codes and were validated through chart review. Rates of SSI and associated risk factors were calculated using univariate regression analysis. Odds ratios were calculated through multivariate logistic regression., Results: A total of 6628 hospital visits were identified. The cumulative incidence of SSI was 2.9%. Procedural risk factors associated with a statistically significant increase in rates of infection were the following: sacral involvement (9.6%), fusions greater than 7 levels (7.8%), fusions greater than 12 levels (10.4%), cases with an osteotomy (6.5%), operative time longer than 5 hours (5.1%), transfusions of red blood cells (5.0%), serum (7.4%), and autologous blood (4.1%). Patient-based risk factors included anemia (4.3%), diabetes mellitus (4.2%), coronary artery disease (4.7%), diagnosis of coagulopathy (7.8%), and bone or connective tissue neoplasm (5.0%)., Conclusion: Used individually, diagnosis-related group, current procedural terminology, and ICD-9 codes cannot completely capture a patient population. Using an algorithm combining all 3 coding systems to generate both inclusion and exclusion criteria, we were able to analyze a specific population of spinal surgery patients within a high-volume medical center. Within that group, risk factors found to increase infection rates were isolated and can serve to focus hospital-wide efforts to decrease surgery-related morbidity and improve patient outcomes.