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Objective: To elucidate risk factors for 90-day readmission in anterior cervical discectomy and fusion (ACDF) for small, medium, and large hospitals. To assess differences in length of stay, charges, and complication rates across hospitals of different size., Methods: A retrospective analysis was performed using elective, single-level ACDF data from 2016 to 2018 in the Healthcare Cost and Utilization Project Nationwide Readmissions Database. Elective single-level ACDF cases were stratified into 3 groups by hospital bed size (small, medium, and large). All-cause complication rates, mean charges, length of stay, and 90-day readmission rates were compared across hospital size. Frequencies of specific comorbidities were compared between readmitted and nonreadmitted patients for each hospital size. Comorbidities significant on univariate analysis were evaluated as independent risk factors for 90-day readmission for each hospital size using multivariate regression., Results: The overall 90-day readmission rate was 6.43% in 36,794 patients, and the rates for small, medium, and large hospitals were 6.25%, 6.28%, and 6.56%, respectively (P = 0.537). Length of stay increased significantly with hospital size (P < 0.001), and small hospitals had the lowest charges (P < 0.001). Although different independent predictors of 90-day readmission were identified for each hospital size, cardiac arrhythmia, chronic pulmonary disease, neurologic disorders, and rheumatic disease were identified as risk factors for hospitals of all sizes., Conclusions: Hospital size is a determining factor for charges and length of stay associated with elective single-level ACDF. Variation in risk factors for readmission exists across hospital size in context of similar 90-day readmission rates., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Study Design: Retrospective cohort., Objective: The aim of this study was to analyze association between social determinants of health (SDH) disparity on postoperative complication rates, and 30-day and 90-day all-cause readmission in patients undergoing single-level lumbar fusions., Summary of Background Data: Decreasing postoperative complication rates is of great interest to surgeons and healthcare systems. Postoperative complications are associated with poor convalescence, inferior patient reported outcomes measures, and increased health care resource utilization. Better understanding of the association between Social Determinants of Health (SDH) on postoperative outcomes maybe helpful to decrease postoperative complication rates., Methods: MARINER 2020, an all-payer claims database, was utilized to identify patients undergoing single-level lumbar fusions between 2010 and 2018. The primary outcomes were the rates of any postoperative complication, symptomatic pseudarthrosis, need for revision surgery, or 30-day and 90-day all-cause readmission., Results: The exact matched population analyzed in this study contained 16,560 patients (8280 [50.0%] patients undergoing single-level lumbar fusion with an SDH disparity; 8280 [50.0%] patients undergoing single-level lumbar fusion without a disparity). Both patient groups were balanced at baseline. The rate of symptomatic pseudarthrosis (1.0% vs. 0.6%, P < 0.05) or any postoperative complication (16.3% vs. 10.4%, P < 0.05) in the matched analysis was higher in the disparity group. The presence of a disparity was associated with 70% increased odds of developing any complication (OR 1.7, 95% CI 1.53-1.84) or symptomatic pseudarthrosis (OR 1.7, 95% CI 1.17-2.37). Unadjusted and adjusted sensitivity analyses yielded similar results as the primary analysis., Conclusion: Social Determinants of Health affect outcomes in spine surgery patients and are associated with an increased risk of developing postoperative complications following lumbar spine fusion.Level of Evidence: 3., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective analysis of data from the National Surgical Quality Improvement Program (NSQIP)., Objective: We sought to compare the short-term outcomes of laminectomy with/without fusion for single-level lumbar degenerative spondylolisthesis (DS)., Summary of Background Data: Lumbar DS is a common cause of low back and radicular pain. Controversy remains over the safety and efficacy of fusion in addition to standard decompressive surgery., Methods: Patients with lumbar DS who underwent laminectomy alone or laminectomy plus posterolateral fusion at a single level were identified from the 2012-2017 NSQIP database. Outcomes included 30-day mortality, major complication, reoperation, readmission, as well as operative duration, need for blood transfusion, length of stay (LOS), and discharge destination. Outcomes were compared between treatment groups by multivariable regression, adjusting for age, sex, and comorbidities (modified Frailty Index). Effect sizes were reported by adjusted odds ratio (aOR) or mean difference (aMD)., Results: The study cohort consisted of 1804 patients; of these, 802 underwent laminectomy alone and 1002 laminectomy plus fusion. On both unadjusted and adjusted analyses, there was no difference in 30-day mortality, major complications, reoperation, or readmission. However, laminectomy plus fusion was associated with longer operative time (170.0 vs. 152.7 minutes; aMD 16.00 minutes, P < 0.001), longer hospital LOS (3.2 vs. 2.5 days; aMD 0.68, P < 0.001), more frequent need for intra- or postoperative blood transfusion (6.8% vs. 3.1%; aOR 2.24, P = 0.001), and less frequent discharge home (80.7% vs. 89.2%; aOR 0.46, P < 0.001)., Conclusion: We found single-level laminectomy plus fusion for lumbar DS to have a comparable short-term safety profile to laminectomy alone. However, fusion was associated with longer operative time and LOS, higher risk of blood transfusion, and greater need for inpatient rehabilitation. These factors should be recognized by clinicians and discussed with patients in the context of their values when weighing surgical treatment of lumbar DS.Level of Evidence: 3., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Longitudinal., Objectives: To evaluate whether the rate of patients who report low health-related quality of life (HRQOL) scores at 2 years following surgical correction of adolescent idiopathic scoliosis (AIS) improves by 5 years postoperatively., Summary of Background Data: HRQOL scores are dependent upon a number of factors and even in instances of good surgical correction of a spinal deformity, are not guaranteed to be high postoperatively. Understanding how a low HRQOL score varies over the postoperative period can help surgeons more effectively counsel patients and temper expectations., Methods: A multicenter database was reviewed for patients with both 2 and 5-year follow-up after spinal fusion and instrumentation for AIS. From a cohort of 916 patients, 52 patients with low HRQOL scores at their 2-year follow-up were identified and reevaluated at 5-year follow-up. A low HRQOL outcome was defined as having SRS-22 domain or total scores less than 2 standard deviations below the mean score. Reoperations were also evaluated to determine if they were associated with HRQOL scores., Results: Of those patients with low SRS-22 HRQOL scores at 2 years postoperatively, improvements were seen in all SRS-22 domains and total scores at the 5-year time point. The greatest change was seen in the satisfaction category where 41 patients showed improvement. The rate of reoperations during this period did not significantly impact patient-reported outcomes., Conclusions: Having a low HRQOL score 2 years after surgery for AIS does not guarantee a low score 5 years after surgery. Promisingly, most patients demonstrate some improvement in all domains for patient-reported SRS-22 scores at 5-year compared to 2-year follow-up. Understanding the longer term postoperative evolution in patient-reported outcomes may help surgeons to effectively manage and counsel patients who are dissatisfied in the short term.Level of Evidence: 3., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

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.)

Study Design: Retrospective review of a multi-institutional data registry., Objective: The authors sought to determine the association between age and complications & patient-reported outcomes (PRO) in patients undergoing multilevel transforaminal interbody lumbar fusion (MTLIF)., Summary of Background Data: Elderly patients undergoing MTLIF are considered high risk. However, data on complications and PRO are lacking. Additionally, safety of multilevel lumbar fusion in the elderly remains uncertain., Methods: Patients ≥50-year-old who underwent MTLIF for degenerative lumbar spine conditions were analyzed. Ninety-day complications and PROs (baseline, 90-d, 1-y, 2-y) were queried using the MSSIC database. PROs were measured by back & leg visual analog scale (VAS), Patient-reported Outcomes Measurement Information System (PROMIS), EuroQol-5D (EQ-5D), and North American Spine Society (NASS) Patient Satisfaction Index. Univariate analyses were used to compare among elderly and complication cohorts. Generalized estimating equation (GEE) was used to identify predictors of complications and PROs., Results: A total of 3120 patients analyzed with 961 (31%) ≥ 70-y-o and 2159 (69%) between 50-69. A higher proportion of elderly experienced postoperative complications (P = .003) including urinary retention (P = <.001) and urinary tract infection (P = .002). Multivariate analysis demonstrated that age was not independently associated with complications. Number of operative levels was associated with any (P = .001) and minor (P = .002) complication. Incurring a complication was independently associated with worse leg VAS and PROMIS scores (P = <.001). Preoperative independent ambulation was independently associated with improved PROMIS, and EQ5D (P = <.001). Within the elderly, preoperative independent ambulation and lower BMI were associated with improved PROMIS (P = <.001). Complications had no significant effect on PROs in the elderly., Conclusions: Age was not associated with complications nor predictive of functional outcomes in patients who underwent MTLIF. Age alone, therefore, may not be an appropriate surrogate for risk. Furthermore, baseline preoperative independent ambulation was associated with better clinical outcomes and should be considered during preoperative surgical counseling.Level of Evidence: 3., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Occipitocervical fusion (OCF) procedures are increasing due to an aging population and the prevalence of trauma, rheumatoid arthritis, and tumors. Reoperation rates and readmission risk factors for cervical fusions have been established, but in relation to OCF they have not been explored. This study investigates the patterns of readmissions and complications following OCF using a national database., Methods: The 2016 U.S. Nationwide Readmissions Database was used for sample collection. Adults (>18 years) who underwent OCF were identified using the 2016 ICD-10 coding system, and we examined the readmission rates (30-day and 90-day) and reoperation rates., Results: Between January and September 2016, a total of 477 patients underwent OCF; the 30-day and 90-day readmission rates were 10.4% and 22.4%, respectively. The 90-day reoperation rate related to the index surgery was 5.7%. Mean age (68.58 years) was significantly greater in the readmitted group versus nonreadmitted group (61.76 years) (P < 0.001). The readmitted group had a significantly higher Charlson Comorbidity Index and Elixhauser Comorbidity Index (5.00 and 2.41, respectively) than the nonreadmitted group (3.25 and 1.15, respectively; P < 0.001). Nonelective OCF showed a higher readmission rate (29.18%) versus elective OCF (12.23%) (P < 0.001). Medicare and Medicaid patients showed the highest rates of readmission (27.27% and 20.41%, respectively). Readmitted patients had higher total health care costs., Conclusions: Nonelective OCF was found to have a readmission rate of almost 2½× that of elective OCF. Understanding risk factors associated with OCF will help with operative planning and patient optimization., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Study Design: Retrospective Study., Objective: This investigation examined matched cohorts of lumbar spinal fusion (LSF) patients undergoing robot-assisted and conventional LSF to compare risk of revision, 30-day readmission, 30-day complications, and postoperative opioid utilization., Summary of Background Data: Patient outcomes and complication rates associated with robot-assisted LSF compared to conventional fusion techniques are incompletely understood., Methods: The PearlDiver Research Program (www.pearldiverinc.com) was used to identify patients undergoing primary LSF between 2011 and 2017. Patients receiving robot-assisted or conventional LSF were matched using key demographic and comorbidity variables. Indication for revision was also studied. Risk of revision, 30-day readmission, 30-day complications, and postoperative opioid utilization at 1 and 6 months was compared between the cohorts using multivariable logistic regression additionally controlling for age, sex, and Charlson Comorbidity Index., Results: The percent of LSFs that were robot-assisted rose by 169% from 2011 to 2017, increasing linearly each year (p = 0.0007). Matching resulted in 2528 patients in each cohort for analysis. Robot-assisted LSF patients experienced higher risk of revision (adjusted odds ratio [aOR] = 2.35, P ≤ 0.0001), 30-day readmission (aOR = 1.39, P = 0.0002), and total 30-day complications (aOR = 1.50, P < 0.0001), specifically respiratory (aOR = 1.56, P = 0.0006), surgical site infection (aOR = 1.56, P = 0.0061), and implant-related complications (aOR = 1.74, P = 0.0038). The risk of revision due to infection after robot-assisted LSF was an estimated 4.5-fold higher (aOR = 4.46, 95% confidence interval [CI] 1.95-12.04, P = 0.0011). Furthermore, robot-assisted LSF had increased risk of revision due to instrument failure (aOR = 1.64, 95% CI 1.05-2.58, P = 0.0300), and pseudarthrosis (aOR = 2.24, 95%CI = 1.32-3.95, P = 0.0037). A higher percentage of revisions were due to infection in robot-assisted LSF (19.0%) than in conventional LSF (9.2%) (P = 0.0408)., Conclusion: Robotic-assisted posterior LSF is independently associated with increased risk of revision surgery, infection, instrumentation complications, and postoperative opioid utilization compared to conventional fusion techniques. Further research is needed to investigate long-term postoperative outcomes following robot-assisted LSF. Spine surgeons should be cautious when considering immediate adoption of this emerging surgical technology., Level of Evidence: 3.

Objective: The primary goal of this study is to determine trends in patient 30-day postoperative readmission and reoperation following elective posterior lumbar fusion (PLF) between 2006-2016., Methods: We retrospectively identified patients in the ACS-NSQIP database who underwent elective, non-emergent PLF from 2006 to 2016. Descriptive statistical and time trend analyses were performed on demographic, comorbidities, perioperative, and outcome variables. Primary outcomes were reoperation and readmission within 30 days and secondary outcomes were medical and surgical complications reported within 30 days of the operation. Linear and binary logistic regression were performed to adjust for patient specific confounders., Results: A total of 26,265 patients underwent elective PLF over the study period. Overall case volume increased from 0.02 % (n = 27) of all total cases in ACS-NSQIP in 2006 to 0.82 % (n = 8228) in 2016. Mean age increased from 51.22 [SE: 2.77] in 2006 to 60.57 [SE: 0.14] in 2016 (p < 0.001). For comorbidities, there was a decrease in smokers and increase in hypertension requiring medication and ASA Class 3. A readmission rate of around 5% per year did not vary significantly over the study period (p = 0.531). Unplanned reoperations declined from 7.4 % in 2006 to 3.1 % in 2016, but the overall trend from 2006 to 2016 was not statistically significant (p = 0.139). Reoperation demonstrated a significant association between age and BMI, but did not vary with admission year. Surgical site infections followed by hematomas and seromas were listed as the most common cause of both readmission and reoperation in PLF patients., Conclusion: Since the establishment of the ACS-NSQIP database, reoperation rates due to complications declined after 2006 and remained relatively stable. Readmissions were added as a variable in 2011 and had no significant changes over time., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Study Design: An epidemiological study using national administrative data from the MarketScan database., Objective: The aim of this study was to identify the impact of bone morphogenetic protein (BMP) on postoperative outcomes in patients undergoing adult cervical deformity (ACD) surgery., Summary of Background Data: BMP has been shown to stimulate bone growth and improve fusion rates in spine surgery. However, the impact of BMP on reoperation rates and postoperative complication rate is controversial., Methods: We queried the MarketScan database to identify patients who underwent ACD surgery from 2007 to 2015. Patients were stratified by BMP use in the index operation. Patients <18 years and those with any history of tumor or trauma were excluded. Baseline demographics and comorbidities, postoperative complication rates, and reoperation rates were analyzed., Results: A total of 13,549 patients underwent primary ACD surgery, of which 1155 (8.5%) had intraoperative BMP use. The overall 90-day complication rate was 27.6% in the non-BMP cohort and 31.1% in the BMP cohort (P < 0.05). Patients in the BMP cohort had longer average length of stay (4.0 days vs. 3.7 days, P < 0.05) but lower revision surgery rates at 90 days (14.5% vs. 28.3%, P < 0.05), 6 months (14.9% vs. 28.6%, P < 0.05), 1 year (15.7% vs. 29.2%, P < 0.05), and 2 years (16.5% vs. 29.9%, P < 0.05) postoperatively. BMP use was associated with higher payments throughout the 2-year follow-up period ($107,975 vs. $97,620, P < 0.05). When controlling for baseline group differences, BMP use independently increased the odds of postoperative complication (odds ratio [OR] 1.22, 95% confidence interval [CI] 1.1-1.4) and reduced the odds of reoperation throughout 2 years of follow-up (OR 0.49, 95% CI 0.4-0.6)., Conclusion: Intraoperative BMP use has benefits for fusion integrity in ACD surgery but is associated with increased postoperative complication rate. Spine surgeons should weigh these benefits and drawbacks to identify optimal candidates for BMP use in ACD surgery., Level of Evidence: 3.

Background: The National Surgical Quality Improvement Program (NSQIP) and National Readmission Database (NRD) are 2 widely used databases that provide valuable information regarding the quality of health care. However, the 2 differ in sampling methodology, which may result in conflicting findings when used for research studies. The objective of this study is to evaluate the differences regarding predictors of 30-day readmissions after anterior cervical discectomy and fusion (ACDF) and posterior lumbar fusion (PLF)., Methods: In this case-control study, NSQIP and NRD were queried for patients undergoing elective ACDF and PLF between 2014 and 2015. The outcome of interest was 30-day readmissions following ACDF and PLF, which were unplanned and related to the index procedure. Subsequently, univariable and multivariable analyses were conducted to determine the predictors of 30-day readmissions using both databases., Results: For ACDF procedures, diagnosis, outpatient status, American Society of Anesthesiologists class, and length of hospital stay were found to be significant predictors of 30-day readmissions in NSQIP, whereas only age and hypertension were significant in NRD. Among patients undergoing PLF procedures, body mass index, functional status, smoking, steroid use, diabetes, dyspnea, dialysis, emergency, discharge to rehab facility, and length of hospital stay were found to be significant predictors of 30-day readmissions in NSQIP, whereas only alcohol abuse and obesity were significant predictors in NRD., Conclusions: Two databases differed in terms of significant predictors of 30-day readmissions following ACDF and PLF. This difference may emphasize the differences in the sampling methodology. Further analyses, potentially with an institutional validation, are needed to draw conclusions regarding the accuracy of the 2 databases for predictive analytics., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Study Design: Retrospective review of the Healthcare Cost and Utilization Project's Kids' Inpatient Database., Objective: The aim of this study was to investigate variations in surgical case volume in the US for spinal arthrodesis for pediatric patients with scoliosis., Summary of Background Data: Approximately 38,000 spinal arthrodesis procedures are performed each year in the United States for pediatric patients with scoliosis. Anecdotally, pediatric spine surgeons report performing more scoliosis procedures during summer months and before national holidays than during other periods, but this has not been reported in the literature. A thorough understanding of seasonal variations in surgical volume may guide the allocation of health care resources., Methods: Using the Healthcare Cost and Utilization Project's Kids' Inpatient Database, we identified 32,563 patients aged <21 years with adolescent idiopathic scoliosis (54%), neuromuscular scoliosis (19%), congenital scoliosis (12%), early-onset scoliosis (12%), or scoliosis from other causes (5%) who underwent primary spinal arthrodesis from 2000 through 2016. χ goodness-of-fit tests were used to evaluate seasonal differences in the number of spinal arthrodesis procedures performed. A negative binomial distribution model was used to compare surgical volume by month. Alpha = 0.05., Results: We found significant seasonal variation in the volume of spinal arthrodesis procedures performed, which persisted after stratifying by type of scoliosis (all, P < 0.001). For all types of scoliosis, surgical volume was highest during the summer. The 3 months with the highest surgical volumes were June, July, and December., Conclusion: The number of spinal arthrodesis procedures performed in the United States for pediatric scoliosis peaked significantly during the summer, with the highest volume of surgeries performed during June, July, and December. An understanding of these variations can help hospitals and providers allocate resources appropriately throughout the year according to predictable changes in surgical volume., Level of Evidence: 4.

Study Design: Retrospective database study., Objective: We sought to identify trends in demographics, comorbidities, and postoperative complications among patients undergoing ACDF and PLF., Summary of Background Data: As demand for anterior cervical discectomy and fusion (ACDF) and posterior lumbar fusion (PLF) surgery continues to increase, it is important to understand changes in the healthcare system and patient populations undergoing these procedures., Methods: We identified 220,520 ACDF and 151,547 PLF surgeries (2006-2016; Premier Healthcare database). Annual proportions or medians were calculated for patient and hospital characteristics, and (Elixhauser) comorbidities. Postoperative complications, including blood transfusions, cardiovascular, pulmonary, renal, or wound complications, hemorrhage, stroke, sepsis, thromboembolism, delirium, inpatient falls, and mortality, were reported per 1000 inpatient days. Trends were assessed by Cochran-Armitage tests and linear regression for binary and continuous variables, respectively., Results: The median age of patients undergoing ACDF and PLF increased significantly from 2006 to 2016 (50 to 57 yr and 58 to 61 yr, respectively; P < 0.001) coinciding with an increasing comorbidity burden (30.2% to 47.9% and 44.9% to 55.7%, respectively representing the share of patients with ≥2 Elixhauser comorbidities; P < 0.001). Overall rate of any complication experienced a significant decline after both ACDF (24.5 to 20.8 per 1000 inpatient days; P = 0.002) and PLF (30.5 to 23.1 per 1000 inpatient days; P < 0.001)., Conclusions: The comorbidity burden of patients undergoing ACDF and PLF increased substantially from 2006 to 2016, however without a corresponding increase in overall complication rate. Understanding these changes can help guide future practice, advise in the allocation of resources, and inform future areas of research., Level of Evidence: 3.

Study Design: Retrospective cohort., Objective: To evaluate the effectiveness and safety of antifibrinolytic (AF) agents in reducing perioperative blood transfusion in pediatric patients undergoing spinal fusion., Summary of Background Data: The potential for AF to decrease bleeding and reduce exposure to allogenic transfusions has led to widespread off-label use in a number of major pediatric surgical procedures. Recent reviews call for improving the body of evidence for their effectiveness and safety in pediatric spinal fusion., Methods: Children undergoing spinal fusion were identified in the American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) 2016 and 2017 databases. Univariate analyses of patient and perioperative characteristics informed the creation of a propensity score model predicting treatment with AF, followed by 1:1 matching to allow comparison of allogenic red blood cell transfusion rates and secondary outcomes between treated and untreated patients., Results: Of 6626 total patients, 5434 (81%) received AF and 1533 (23%) received a blood transfusion. Analysis of data for 1192 propensity score-matched pairs revealed that treatment with AF was associated with a statistically nonsignificant 16% reduction in perioperative transfusion (OR 0.84, 95% confidence interval 0.68-1.05, P = 0.119) and a statistically significant 43% reduction in postoperative transfusion (OR 0.57, 95% confidence interval 0.39-0.81, P = 0.002). No differences in the incidences of postoperative seizure or thrombosis were observed, with overall rates of 7.5 and 22.5 events per 10,000 patients, respectively., Conclusion: AF agents appear to reduce postoperative allogenic transfusion in children undergoing spinal fusion surgery. Adverse drug effects such as thromboembolic complications and seizure were extremely rare and warrant continued monitoring, though this is the largest study to date providing evidence for the safety profile of these drugs., Level of Evidence: 3.

Study Design: Retrospective study., Objective: To determine how lumbar spinal fusion-total hip arthroplasty (LSF-THA) operative sequence would affect THA outcomes., Summary of Background Data: Outcomes following THA in patients with a history of lumbar spinal degenerative disease and fusion are incompletely understood., Methods: The PearlDiver Research Program (http://www.pearldiverinc.com) was used to identify patients undergoing primary THA. Patients were divided into four cohorts: 1) Primary THA without spine pathology, 2) remote LSF prior to hip pathology and THA, and patients with concurrent hip and spinal pathology that had 3) THA following LSF, and 4) THA prior to LSF. Postoperative complications and opioid use were assessed with multivariable logistic regression to determine the effect of spinal degenerative disease and operative sequence., Results: Between 2007 and 2017, 85,595 patients underwent primary THA, of whom 93.6% had THA without lumbar spine degenerative disease, 0.7% had a history of remote LSF, and those with concurrent hip and spine pathology, 1.6% had THA prior to LSF, and 2.4% had THA following LSF. Patients with hip and lumbar spine pathology who underwent THA prior to LSF had significantly higher rates of dislocation (aOR = 2.46, P < 0.0001), infection (aOR = 2.65, P < 0.0001), revision surgery (aOR = 1.91, P < 0.0001), and postoperative opioid use at 1 month (aOR: 1.63, P < 0.001), 3 months (aOR = 1.80, P < 0.001), 6 months (aOR: 2.69, P < 0.001), and 12 months (aOR = 3.28, P < 0.001) compared with those treated with THA following LSF., Conclusion: Patients with degenerative hip and lumbar spine pathology who undergo THA prior to LSF have a significantly increased risk of postoperative dislocation, infection, revision surgery, and prolonged opioid use compared with THA after LSF. Surgeons should consider the surgical sequence of THA and LSF on outcomes for patients with this dual pathology. Shared decision making between patients, spine surgeons, and arthroplasty surgeons is necessary to optimize outcomes in patients with concomitant hip and spine pathology., Level of Evidence: 3.

MINI: It is unclear whether the ACS NSQIP Surgical Risk Calculator can predict 30-day complications after lumbar and cervical spinal fusions. This study shows that the Risk Calculator is only of marginal benefit in predicting outcomes in cervical fusion and unlikely to be of benefit in lumbar fusions., Study Design: Retrospective cohort study., Objective: The aim of this study was to assess the American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) Risk Calculator's ability to predict 30-day complications after spine surgery., Summary of Background Data: Surgical risk calculators may identify patients at increased risk for complications, improve outcomes, enhance the informed consent process, and help modify risk factors. The ACS NSQIP Risk Calculator was developed from a cohort of >1.4 million patients, using 2805 unique CPT codes. It uses 21 patient predictors and the planned procedure to predict the risk of 12 different outcomes within 30 days following surgery., Methods: A retrospective chart review was performed on patients who underwent primary lumbar and cervical fusions with at least 30-day postoperative follow-up between 2009 and 2015 at a single-institution. Descriptive statistics were calculated for the overall sample, anterior versus posterior fusion (cervical only), and single versus multilevel fusion. Logistic regression models were fit with actual complication occurrence as the dependent variable in each model and ACS estimated risk as the independent variable. The c-statistic was used as the measure of concordance for each model. Receiver-operating charateristic curves depicted the predictive ability of the estimated risks. Acceptable concordance was set at c >0.80., Results: A total of 237 lumbar and 404 cervical patients were included in the study. The Risk Calculator risk estimates significantly predicted (P < 0.001) "any complication" and "discharge to skilled nursing facility" among the cervical cohort and demonstrated no significant outcome prediction the lumbar cohort., Conclusion: The ACS Risk-Calculator accurately predicted complications in the categories of "any complication" and "discharge to skilled nursing facility" for our cervical cohort and failed to demonstrate benefit for our lumbar cohort. Although the ACS Risk-Calculator may be useful in general surgery, our findings demonstrate that it does not necessarily provide accurate information for patients undergoing spinal surgery., Level of Evidence: 3.

Study Design: Retrospective cohort study., Objective: The objective of this study was to characterize the costs associated with American Society of Anesthesiologists (ASA) class, and to determine the extent to which ASA status is a predictor of increased cost and LOS following lumbar laminectomy and fusion (LLF)., Summary of Background Data: Spinal fusion accounts for the highest hospital costs of any surgical procedure performed in the United States, and ASA (American Society of Anesthesiologists) status is a known risk factor for cost and length of stay (LOS) in the orthopedic literature. There is a paucity of literature that directly addresses the influence of ASA status on cost and LOS following LLF., Methods: This is a retrospective cohort study of an institutional database of patients undergoing single-level LLF at an academic tertiary care facility from 2006 to 2016. Univariate comparisons were made using χ tests for categorical variables and t tests for continuous variables. Multivariate linear regression was utilized to estimate regression coefficients, and to determine whether ASA status is an independent risk factor for cost and LOS., Results: A total of 1849 patients met inclusion criteria. For every one-point increase in ASA score, intensive care unit (ICU) LOS increased by 0.518 days (P < 0.001), and hospital length of stay increased by 1.93 days (P < 0.001). For every one-point increase in ASA score, direct cost increased by $7474.62 (P < 0.001)., Conclusion: ASA status is a predictor of hospital LOS, ICU LOS, and direct cost. Consideration of the ways in which ASA status contributes to increased cost and prolonged LOS can allow for more accurate reimbursement adjustment and more precise targeting of efficiency and cost effectiveness initiatives., Level of Evidence: 3.

Background: Previous reports have suggested an increasing rate of utilization of spinal fusions, but contemporary data have not been analyzed, and there has been little investigation of putative drivers of increased utilization., Objective: To investigate whether there is an ongoing trend of increased utilization of spinal fusions in recent data, and if there may be associations with an increasing proportion of elderly in the population, changing patterns of payer-types, and changing reimbursement rates., Methods: We analyze 7.1 million cases from the National Inpatient Sample between 1998 and 2014. We measure annual utilization per 100 000 persons and conduct trend analyses with subgroup analysis of the senior (65 + ) population. Spine surgery utilization is compared with nonspine surgical procedures (coronary artery bypass grafting, hernia repair, hip, and knee replacement). We assess trends in charges, payer type, Medicare reimbursement rates, and hospital type., Results: There was an 88% increase in the utilization rate of spinal fusion procedures from 1998 to 2014 (from 74 to 139 cases per 100 000 persons) with a significant upward trend (P < .001) that persisted in the 65 + subgroup (P < .001). An increasing proportion of spinal fusions is paid for by public payers, but per-procedure reimbursement for spinal fusions by Medicare has decreased recently (5% reduction from 2014 to 2016)., Conclusion: Utilization of spinal fusions continues to increase and is not explained by increased proportion of elderly in the population, increased utilization of surgeries across specialties, or increased Medicare reimbursement. In fact, increased utilization of spinal fusions temporally correlated with decreasing per-procedure Medicare reimbursement., (Copyright © 2019 by the Congress of Neurological Surgeons.)

Study Design: Retrospective cohort study., Objective: The aim of this study was to determine the differences in 30-day readmission, reoperation, and morbidity for patients undergoing multilevel anterior cervical discectomy and fusion (ACDF) or single and multilevel anterior cervical corpectomy and fusion (ACCF)., Summary of Background Data: Despite increasing rates of surgical treatment of cervical spine disease, few studies have compared outcomes by surgical technique. To the best of our knowledge, this is the only large-scale administrative database study that directly evaluates early outcomes between multilevel ACDF and single and multilevel ACCF., Methods: Patients who underwent ACDF and ACCF were identified using the NSQIP database. Multivariate regression was utilized to compare rates of readmission, reoperation, morbidity, and specific complications between surgical techniques, and to evaluate for predictors of primary outcomes., Results: We identified 15,600 patients. ACCF independently predicted (P < 0.001) greater reoperation (odds ratio [OR] = 1.876) and morbidity (OR = 1.700), but not readmission, on multivariate analysis. ACCF was also associated with greater rates of transfusion (OR = 3.273, P < 0.001) and DVT/thrombophlebitis (OR = 2.852, P = 0.001). ACCF had significantly (P < 0.001) greater operative time and length of stay. In the cohort, increasing age (P < 0.001), diabetes (P = 0.025), chronic obstructive pulmonary disease (P = 0.027), disseminated cancer (P = 0.009), and American Society of Anesthesiologists (ASA) class ≥3 (P < 0.001) predicted readmission. Age (P = 0.011), female sex (P = 0.001), heart failure (P = 0.002), ASA class ≥3 (P < 0.001), and increased creatinine (P = 0.044), white cell count (P = 0.033), and length of stay (P < 0.001) predicted reoperation. Age (P < 0.001), female sex (P = 0.002), disseminated cancer (P = 0.010), ASA class ≥3 (P < 0.001), increased white cell count (P = 0.036) and length of stay (P < 0.001), and decreased hematocrit (P < 0.001) predicted morbidity. Within ACDF, three or more levels treated compared to two levels did not predict poorer 30-day outcomes., Conclusion: Compared to multilevel ACDF, ACCF was associated with an 88% increased odds of reoperation and 70% increased odds of morbidity; readmission was similar between techniques. Older age, higher ASA class, and specific comorbidities predicted poorer 30-day outcomes. These findings can guide surgical solution given specific factors., Level of Evidence: 3.

Background: Patients with chronic renal failure undergoing hemodialysis have been shown to have poor overall health, osteoporosis, and altered bone metabolism. However, the impact of hemodialysis on patient outcomes after spinal fusion remains unknown. We sought to assess the effect of dialysis on 30-day perioperative and postoperative outcomes after cervical and lumbar fusion for pathologic compression fractures., Methods: We queried the National Surgical Quality Improvement Program from 2009 to 2016 for patients undergoing cervical or lumbar fusion for compression fractures. Three-to-one propensity score matching using sex, age, body mass index, and number of operated levels was used to match patients not undergoing dialysis with those undergoing dialysis. Multivariable conditional regression was used to identify the association between dialysis and 30-day clinical outcomes, after adjusting for confounders., Results: A total of 48,492 patients undergoing cervical fusion were identified; 156 (0.32%) of these were on dialysis. On multivariable regression, dialysis dependency was associated with increased operative time (regression coefficient [coef.], 15.93; 95% CI, 0.4-31.5; P = 0.045), length of stay (coef. 6.06; 95% CI, 4.64-7.48; P < 0.001), 30-day readmissions (odds ratio [OR], 1.07; 95% CI, 1.02-1.12; P = 0.009), any complications (OR 1.08; 95% CI, 1.03-1.13; P = 0.002), and serious complications (OR, 1.08; 95% CI, 1.02-1.14; P = 0.012). A total of 25,417 patients undergoing lumbar fusion were identified; 51 of these (0.2%) were on dialysis. On multivariable regression, dialysis dependency was associated with significantly higher length of stay (coef. 2.98; 95% CI, 1.28-4.68; P < 0.001)., Conclusions: Our analyses indicated that dialysis dependency is associated with poor perioperative and postoperative outcomes after cervical/lumbar fusion for pathologic compression fractures., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: The reoperation rate after lumbar degenerative disease surgery is low. It is difficult to find statistical differences in reoperation rates according to the different diagnoses of lumbar degenerative diseases. National population-based database overcomes the statistical problem by its large cohorts with longitudinal follow-up in a nation. The purpose was to compare the reoperation rates after single-level lumbar spinal posterior decompression and fusion surgeries depending on different preoperative diagnoses of lumbar degenerative disease., Patients and Methods: We used the Korean Health Insurance Review & Assessment Service national database. The study population was the patients with a diagnosis of a degenerative lumbar disease who underwent single-level decompression and fusion from January 1, 2011, to June 30, 2016. We classified the patients into one of three groups based on diagnosis codes of lumbar disc herniation, spondylolisthesis, or spinal stenosis. A reoperation was defined as repeated decompression and fusion. We considered age, sex, the presence of diabetes, osteoporosis, associated comorbidities, and hospital types as potential confounding factors., Results: The reoperation rate was higher in patients with spinal stenosis than in those with lumbar disc herniation. However, there was no difference in the reoperation rate between the patients with lumbar disc herniation and those with spondylolisthesis. Male gender and hospital type were risk factors for reoperation., Conclusion: The incidence of reoperation was dependent on the diagnostic subgroups of lumbar degenerative diseases. This information can help surgeons accurately communicate with their patients and enhance the preoperative informed consent process., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Recurrent lumbar disc herniation is a common negative sequela of primary discectomy. Repeat discectomy versus spinal fusion is constantly debated, and successful outcomes from both treatments remain unclear. Several meta-analysis studies have not reported re-operative rates between the two treatment methods; therefore, we seek to report these outcomes in the following systematic review and meta-analysis design study. The primary objective was to compare re-operative rates between repeat discectomy and fusion treatment. The secondary objectives included comparing clinical improvement, operative time, blood loss, complications, and postoperative hospital stay between repeat discectomy and fusion treatment. The data were gathered from the following sources: PubMed Medline, Ovid Medline, Cochrane database, and Google Scholars. Only comparative studies in humans were selected. There were initially 182 citations found. After the analysis, we found four studies that were compatible with our inclusion criteria. The meta-analysis showed that the re-operative rate seemed to be higher in the discectomy group (9.09%) compared with the fusion group (2.00%), but the difference was not statistically significant. The primary cause of re-operation in the discectomy group is recurrent disc herniation. Two causes of re-operation in the fusion group are adjacent segmental degeneration and implant removal. Operative time and postoperative stay were significantly less in the discectomy group. The improvement rate was not different between the two groups. In conclusion, no difference in re-operation rates between the two surgical treatments was found based on the results of our study. Both treatment techniques have equal improvement rates and complications., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Study Design: Retrospective cohort study OBJECTIVE.: To study 30- and 90-day readmission rates, causes, and risk factors after anterior cervical discectomy and fusion (ACDF) and posterior cervical fusion (PCF)., Summary of Background Data: Existing data on readmission after cervical fusion is majorly derived from national databases. Given their inherent limitations in accuracy, follow-up available, and missing data, we intend to add to literature from our institutional analysis., Methods: Patients who underwent ACDF and PCF for degenerative cervical pathology in 2013 and 2014 were identified for the study. Comprehensive chart review was performed to record demographics and clinical patient profile. Hospital readmission within 30 and 90 days was identified, and the causes and management were recorded. Binary logistic regression analysis was done to study risk factors for readmission. ACDF and PCF were studied separately., Results: Our analysis included a total of 549 patients, stratified as 389 ACDFs and 160 PCFs. The 30- and 90-day unplanned readmission rate was 5.1% and 7.7% after ACDF. These rates were 11.2% and 16.9% after PCF. The most common cause of readmission was systemic infection and sepsis after ACDF and PCF (31.4% and 25.8% of readmitted, respectively), followed by pulmonary complications after ACDF (14.3% of readmitted) and wound complications after PCF (19.4% of readmitted). Predictors of readmission after ACDF included heart failure, history of malignancy, history of deep vein thrombosis/pulmonary embolism, and any intraoperative complication. In the PCF cohort, history of ischemic heart disease, increasing number of fusion levels and longer length of stay were independently predictive., Conclusion: The rates, causes, and risk factors of readmission after ACDF and PCF have been identified. There is variation in published data regarding the incidence and risk factors for readmission after cervical fusion; however, majority of readmissions occur due to medical complications and systemic infection., Level of Evidence: 3.

Study Design: Retrospective review of prospective multicenter database., Objective: To identify an optimal set of factors predicting the risk of proximal junctional failure (PJF) while taking the time dependency of PJF and those factors into account., Summary of Background Data: Surgical correction of adult spinal deformity (ASD) can be complex and therefore, may come with high revision rates due to PJF., Methods: Seven hundred sixty-three operative ASD patients with a minimum of 1-year follow-up were included. PJF was defined as any type of proximal junctional kyphosis (PJK) requiring revision surgery. Time-dependent ROC curves were estimated with corresponding Cox proportional hazard models. The predictive abilities of demographic, surgical, radiographic parameters, and their possible combinations were assessed sequentially. The area under the curve (AUC) was used to evaluate models' performance., Results: PJF occurred in 42 patients (6%), with a median time to revision of approximately 1 year. Larger preoperative pelvic tilt (PT) (hazard ratio [HR]=1.044, P = 0.034) significantly increased the risk of PJF. With respect to changes in the radiographic parameters at 6-week postsurgery, larger differences in pelvic incidence-lumbar lordosis (PI-LL) mismatch (HR = 0.924, P = 0.002) decreased risk of PJF. The combination of demographic, surgical, and radiographic parameters has the best predictive ability for the occurrence of PJF (AUC = 0.863), followed by demographic along with radiographic parameters (AUC = 0.859). Both models' predictive ability was preserved over time., Conclusions: Over correction increased the risk of PJF. Radiographic along with demographic parameters have shown the approximately equivalent predictive ability for PJF over time as with the addition of surgical parameters. Radiographic rather than surgical factors may be of particular importance in predicting the development of PJF over time. These results set the groundwork for risk stratification and corresponding prophylactic interventions for patients undergoing ASD surgery., Level of Evidence: 4.

Objectives: Reported incidence of dysphagia after ACDFs has been as high as 79%. There, however, have been no studies that have specifically looked at developing a criteria for reducing the incidence of dysphagia for outpatient ACDFs. The aim of this study was to determine the risks factors for significant dysphagia that will exclude patients from outpatient single-level anterior cervical discectomy and fusions (ACDFs)., Patients and Methods: Using the Kaiser Permanente Spine registry database, between January 2009 and September 2013, we identified all inpatients (there were no outpatients) who underwent primary elective one-level ACDFs. A cohort of patients were identified with in-hospital length of stay (LOS) > 48 h in which the reason for continued admission was primarily significant dysphagia (DG). Patient's demographics and intraoperative data (ACDF levels (upper [C2-3, C3-4], middle [C4-5, C5-6], lower [C6-7, C7-T1]), and operative times (<100, 100-199, ≥ 200, minutes)) was used to determine risk factors for dysphagia., Results: We found 747 single-level ACDF cases with a cohort of 239 (32.0%) who met the criteria for dysphagia (DG) with > 48 h admission. The DG group and non-dysphagia group (NDG) had similar demographics. Diabetes was excluded from regression analysis due to the low frequency. Compared to the lower spine level (C5-6, C7-T1), the upper spine level (C2-3, C3-4) ACDF had a higher likelihood for dysphagia (OR = 2.23, 95% CI = 1.35-3.68, p = 0.0016); no difference was found for middle spine level (C4-5, C5-6) ACDF., Conclusion: Single-level ACDF at the upper cervical spine (C2-3, C3-4) was found to be the only risk factor for dysphagia with LOS > 48 h based on inpatient data from a spine registry. Age, BMI category, gender, ASA classification, smoking, and operative time were not predictive factors. These findings should be used for excluding patients who undergo outpatient single-level ACDF surgery to reduce significant postoperative dysphagia., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Study Design: A retrospective cohort study., Objective: The aim of this study was to determine the difference in 30-day readmission, reoperation, and morbidity for patients undergoing either posterior or anterior lumbar interbody fusion., Summary of Background Data: Despite increasing utilization of lumbar interbody fusion to treat spinal pathology, few studies compare outcomes by surgical approach, particularly using large nationally represented cohorts., Methods: Patients who underwent lumbar interbody fusion were identified using the NSQIP database. Rates of readmission, reoperation, morbidity, and associated predictors were compared between posterior/transforaminal (PLIF/TLIF) and anterior/lateral (ALIF/LLIF) lumbar interbody fusion using multivariate regression. Bonferroni-adjusted alpha-levels were utilized whereby variables were significant if their P values were less than the alpha-level or trending if their P values were between 0.05 and the alpha-level., Results: We identified 26,336 patients. PLIF/TLIF had greater operative time (P = 0.015), transfusion (P < 0.001), UTI (P = 0.008), and stroke/CVA (P = 0.026), but lower prolonged ventilation (P < 0.001) and DVT (P = 0.002) rates than ALIF/LLIF. PLIF/TLIF independently predicted greater morbidity on multivariate analysis (odds ratio: 1.155, P = 0.0019).In both groups, experiencing a complication and, in PLIF/TLIF, ASA-class ≥3 predicted readmission (P < 0.001). Increased age trended toward readmission in ALIF/LLIF (P = 0.003); increased white cell count (P = 0.003), dyspnea (P = 0.030), and COPD (P = 0.005) trended in PLIF/TLIF. In both groups, increased hospital stay and wound/site-related complication predicted reoperation (P < 0.001). Adjunctive posterolateral fusion predicted reduced reoperation in ALIF/LLIF (P = 0.0018). ASA-class ≥3 (P = 0.016) and age (P = 0.021) trended toward reoperation in PLIF/TLIF and ALIF/LLIF, respectively. In both groups, age, hospital stay, reduced hematocrit, dyspnea, ASA-class ≥3, posterolateral fusion, and revision surgery and, in PLIF/TLIF, bleeding disorder predicted morbidity (P < 0.001). Female sex (P = 0.010), diabetes (P = 0.042), COPD (P = 0.011), and disseminated cancer (P = 0.032) trended toward morbidity in PLIF/TLIF; obesity trended in PLIF/TLIF (P = 0.0022) and ALIF/LLIF (P = 0.020)., Conclusion: PLIF/TLIF was associated with a 15.5% increased odds of morbidity; readmission and reoperation were similar between approaches. Older age, higher ASA-class, and specific comorbidities predicted poorer 30-day outcomes, while procedural-related factors predicted only morbidity. These findings can guide surgical approach given specific factors., Level of Evidence: 3.

Study Design: A retrospective case-control study., Objective: The aim of this study was to determine the nationwide trends and complication rates associated with outpatient posterior lumbar fusion (PLF)., Summary of Background Data: Outpatient lumbar spine fusion is now possible secondary to minimally invasive techniques that allow for reduced hospital stays and analgesic requirements. Limited data are currently available regarding the clinical outcome of outpatient lumbar fusion., Methods: The Humana administrative claims database was queried for patients who underwent one to two-level PLF (CPT-22612 or CPT-22633 AND ICD-9-816.2) as either outpatients or inpatients from Q1 2007 to Q2 2015. The incidence of perioperative medical and surgical complications was determined by querying for relevant International Classification of Diseases and Current Procedural Terminology codes. Multivariate logistic regression adjusting for age, gender, and Charlson Comorbidity Index was used to calculate odds ratios (ORs) of complications among outpatients relative to inpatients undergoing PLF., Results: Cohorts of 770 patients who underwent outpatient PLF and 26,826 patients who underwent inpatient PLF were identified. The median age was in the 65 to 69 years age group for both cohorts. The annual relative incidence of outpatient PLF remained stable across the study period (R = 0.03, P = 0.646). Adjusting for age, gender, and comorbidities, patients undergoing outpatient PLF had higher likelihood of revision/extension of posterior fusion [(OR 2.33, confidence interval (CI) 2.06-2.63, P < 0.001], anterior fusion (OR 1.64, CI 1.31-2.04, P < 0.001), and decompressive laminectomy (OR 2.01, CI 1.74-2.33, P < 0.001) within 1 year. Risk-adjusted rates of all other postoperative surgical and medical complications were statistically comparable., Conclusion: Outpatient lumbar fusion is uncommonly performed in the United States. Data collected from a national private insurance database demonstrate a greater risk of postoperative surgical complications including revision anterior and posterior fusion and decompressive laminectomy. Surgeons should be cautious in performing PLF in the outpatient setting, as the risk of revision surgery may increase in these cases., Level of Evidence: 3.

Objective: To evaluate the impact of cigarette smoking on the development of wound complications, including wound dehiscence, superficial infection, deep infection, or organ space infection, within the first 30 postoperative days in patients undergoing surgery for spondylolisthesis., Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for the years 2012-2014 was used to identify adult patients who underwent single-level posterolateral fusion (PLF) or interbody fusion for spondylolisthesis. Wound complications occurring within 30 days were compared between current smokers and nonsmokers., Results: A total of 1688 patients who underwent single-level PLF or interbody fusion for spondylolisthesis were identified, among whom 271 were current smokers (16.1%). The overall wound complication rate was 3.3% for smokers versus 1.8% for nonsmokers (P = 0.095). When stratified by operative technique, the rate of wound complications was not significantly different between smokers and nonsmokers undergoing PLF (2.4% vs. 2.6%; P = 1.00); however, smokers who underwent interbody fusion were more likely to experience a wound complication compared with nonsmokers undergoing interbody fusion (3.7% vs. 1.3%; P = 0.028). On multivariate analysis, smoking was an independent predictor of organ/space infection irrespective of fusion technique used (odds ratio, 15.4; 95% confidence interval, 1.34-175.4; P = 0.028)., Conclusions: The rate of wound complications was not higher in smokers undergoing PLF alone, but was significantly higher in smokers who underwent interbody fusion. However, multivariate analysis identified smoking as an independent predictor of organ/space infection irrespective of fusion technique used., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Study Design: A retrospective review of the Statewide Planning and Research Cooperative System database of the New York State., Objective: This study examined the rate of increase of cervical spine fusion procedures at low-, medium-, and high-volume hospitals, and analyzed racial and socioeconomic characteristics of the patient population treated at these three volume categories., Summary of Background Data: There has been a steady increase in spinal fusion procedures performed each year in the United States, especially cervical and lumbar fusion. Our study aims to analyze the rate of increase at low-, medium-, and high-volume hospitals, and socioeconomic characteristics of the patient populations at these three volume categories., Methods: The New York State, Statewide Planning and Research Cooperative System (SPARCS) database was searched from 2005 to 2014 for the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Procedure Codes 81.01 (Fusion, atlas-axis), 81.02 (Fusion, anterior column, other cervical, anterior technique), and 81.03 (Fusion, posterior column, other cervical, posterior technique). Patients' primary diagnosis (ICD-9-CM), age, race/ethnicity, primary payment method, severity of illness, length of stay, hospital of operation were included. All 122 hospitals were categorized into high-, medium-, and low-volume. Trends in annual number of cervical spine fusion surgeries in each of the three hospital volume groups were reported using descriptive statistics., Results: Low-volumes centers were more likely to be rural and non-teaching hospitals. African American patients comprised a greater portion of patients at low-volume hospitals, 15.1% versus 11.6% compared with high-volume hospitals. Medicaid and self-pay patients were also overrepresented at low-volume centers, 6.7% and 3.9% versus 2.6% and 1.7%, respectively. Compared with Caucasian patients, African American patients had higher rates of postoperative infection (P = 0.0020) and postoperative bleeding (P = 0.0044). Compared with privately insured patients, Medicaid patients had a higher rate of postoperative bleeding (P = 0.0266) and in-hospital mortality (P = 0.0031)., Conclusion: Our results showed significant differences in hospital characteristics, racial distribution, and primary payments methods between the low- and high-volume categories. African American and Medicaid patients had higher rates of postoperative bleeding, despite similar rates between the three volume categories. This suggests racial and socioeconomic disparities remains problematic for disadvantaged populations, some of which may be attributed to accessibility to care at high-volume centers., Level of Evidence: 3.

Objective: This study examined the distribution of spinal fusion usage among payer groups in the United States., Methods: Using the National Inpatient Sample (NIS) database, total discharges, length of stay, and mean hospital charges of patients who underwent spinal fusion from 1997 to 2014 in the United States were determined and analyzed., Results: 5,715,625 total discharges with spinal fusion were reported. Among them, 2,875,188 (50.3%) were covered by private insurance, 1,710,182 by Medicare (29.9%), 342,638 (6.0%) by Medicaid, and 91,990 (1.6%) were uninsured. A statistically significant increase in spinal fusion usage occurred within each payer group over the study period (P < 0.001). For every year of the study period, private insurance patients had the most number and uninsured patients had the least number of total discharges with spinal fusion. Furthermore, annual growth in spinal fusion usage was greatest among private insurance patients, and smallest among uninsured patients., Conclusions: Total discharges with spinal fusion increased significantly across all payer groups between 1997 and 2014, but not equally. Further inquiry is indicated to determine the etiology of spinal fusion usage discrepancies between payer groups., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: The optimal form of treatment for C2 spine fractures is controversial. This investigation analyzed the variations in treatment of C2 fractures over time, by age group, and by geographic location., Methods: The Nationwide Emergency Department Sample database was queried to identify patients 18 years and older who sustained C2 fracture without neurologic injury from 2006 to 2012. Subsequently, patients were further filtered based on the intervention they received: collar, halo, and surgery. Regions of hospital used in analysis were defined as Northeast, Midwest, South, and West. Linear regression models were used to analyze trends for C2 incidence rates and treatment type. Analysis of variance tests were used to determine differences among procedure groups when stratified by regions and age groups., Results: Surgical intervention for C2 fracture increased from 36.5% in 2006 to 55.7% in 2012 (r = 0.116, P < 0.001). In contrast, the rate of halo use decreased from 57.8% in 2006 to 37.1% in 2012 (r = -0.139, P < 0.001). Surgery displayed increasing trend across all age groups. A greater proportion of patients in the Northeast were treated by collar compared with all other regions (P < 0.001). In contrast, halo use was significantly lower in the Northeast than the other 3 regions (P < 0.001)., Conclusions: This investigation demonstrated that surgical management of C2 fractures is increasing in frequency over time and at all age groups. Furthermore, the treatment of these fractures varies by region-the Northeast had the highest incidence of collar use and lowest rate of halo use., (Copyright © 2018 Elsevier Inc. All rights reserved.)

OBJECTIVE Efforts to examine the value of care-combining both costs and quality-are gaining importance in the current health care climate. This thrust is particularly evident in treating common spinal disease where both incidences and costs are generally high and practice patterns are variable. It is often challenging to obtain direct surgical costs for these analyses, which hinders the understanding of cost drivers and cost variation. Using a novel tool, the authors sought to understand the costs of posterior lumbar arthrodesis with interbody devices. METHODS The Value Driven Outcomes (VDO) database at the University of Utah was used to evaluate the care of patients who underwent open or minimally invasive surgery (MIS), 1- and 2-level lumbar spine fusion (Current Procedural Terminology code 22263). Patients treated from January 2012 through June 2017 were included. RESULTS A total of 276 patients (mean age 58.9 ± 12.4 years) were identified; 46.7% of patients were men. Most patients (82.2%) underwent 1-level fusion. Thirteen patients (4.7%) had major complications and 11 (4.1%) had minor complications. MIS (β = 0.16, p = 0.002), length of stay (β = 0.47, p = 0.0001), and number of operated levels (β = 0.37, p = 0.0001) predicted costs in a multivariable analysis. Supplies and implants (55%) and facility cost (36%) accounted for most of the expenditure. Other costs included pharmacy (7%), laboratory (1%), and imaging (1%). CONCLUSIONS These results provide direct cost accounting for lumbar fusion procedures using the VDO database. Efforts to improve the value of lumbar surgery should focus on high cost areas, i.e., facility and supplies/implant.

Background: Several studies suggest significant variation in cost for spine surgery, but there has been little research in this area for spinal deformity., Objective: To determine the utilization, cost, and factors contributing to cost for spinal deformity surgery., Methods: The cohort comprised 55 599 adults who underwent spinal deformity fusion in the 2001 to 2013 National Inpatient Sample database. Patient variables included age, gender, insurance, median income of zip code, county population, severity of illness, mortality risk, number of comorbidities, length of stay, elective vs nonelective case. Hospital variables included bed size, wage index, hospital type (rural, urban nonteaching, urban teaching), and geographical region. The outcome was total hospital cost for deformity surgery. Statistics included univariate and multivariate regression analyses., Results: The number of spinal deformity cases increased from 1803 in 2001 (rate: 4.16 per 100 000 adults) to 6728 in 2013 (rate: 13.9 per 100 000). Utilization of interbody fusion devices increased steadily during this time period, while bone morphogenic protein usage peaked in 2010 and declined thereafter. The mean inflation-adjusted case cost rose from $32 671 to $43 433 over the same time period. Multivariate analyses showed the following patient factors were associated with cost: age, race, insurance, severity of illness, length of stay, and elective admission (P < .01). Hospitals in the western United States and those with higher wage indices or smaller bed sizes were significantly more expensive (P < .05)., Conclusion: The rate of adult spinal deformity surgery and the mean case cost increased from 2001 to 2013, exceeding the rate of inflation. Both patient and hospital factors are important contributors to cost variation for spinal deformity surgery., (Copyright © 2017 by the Congress of Neurological Surgeons)

Study Design: Prospective cohort study., Objective: To prospectively compare radiographic, perioperative, and functional outcomes between anterior spinal instrumentation and fusion (ASIF) and posterior spinal instrumentation and fusion (PSIF) in Lenke 5C curves., Summary of Background Data: Historically, ASIF has been the treatment of choice for treatment of thoracolumbar adolescent idiopathic scoliosis. More recently, PSIF has gained popularity for its ease, versatility, and amount of correction achieved. Current literature lacks a prospective comparative analysis between these two approaches to better aid treating surgeons in decision making when treating Lenke 5C curves., Methods: A prospective, longitudinal multicenter adolescent idiopathic scoliosis database was used to identify 161 consecutive patients with Lenke 5C curves treated by ASIF with a dual rod system, or PSIF with a pedicle screw-rod construct. Pre- and 2-year postoperative radiographic data, Scoliosis Research Society outcome scores, and perioperative comparisons were made between the two approaches., Results: A total of 69 patients were treated with ASIF and 92 patients with PSIF. Curve extent, magnitude, stable, and end vertebrae distribution before surgery were similar between the two groups. At 2-year follow-up, there were no significant differences in percentage correction of the main curve (ASIF: 59.1%, PSIF: 59.6%), C7 decompensation (ASIF: -0.6 ± 1.2, PSIF: -0.3 ± 1.4 cm), length of hospital stay (ASIF: 5.6 days, PSIF: 5.7 days), postoperative day conversion to oral pain medication (ASIF: 3.2 days, PSIF: 3.2 days), and SRS outcome scores (P = 0.560) between the two groups. The number of levels fused was significantly lower in ASIF group (ASIF: 4.7, PSIF: 6.3; P < 0.001), but PSIF resulted in significantly less disc angulation below lowest instrumented vertebrae (ASIF: 3.4°, PSIF: 1.7°; P = 0.011), greater lumbar lordosis (P < 0.001), and greater % correction of lumbar prominence (P = 0.017)., Conclusion: The amount of correction achieved was similar between ASIF and PSIF. ASIF resulted in shorter fusions (average 1.6 levels) compared with PSIF. This was at the expense of increased disc angulation below the lowest instrumented vertebrae, less lumbar lordosis, and a lower % correction of the lumbar prominence than PSIF., Level of Evidence: 2.

Study Design: A retrospective analysis of population-based national hospital discharge data collected for the Nationwide Inpatient Sample., Objective: To examine the demographics and in-hospital outcomes of patients with solid organ transplant (SOT) undergoing spinal fusion on a national level., Summary of Background Data: Solid organ transplantation has become more common in recent years and some of these patients undergo spinal fusion surgery. There is, however, little information regarding the trends and outcomes in such patients., Methods: Clinical data were derived from the US Nationwide Inpatient Sample between 2000 and 2009. Patients with or without SOT who underwent spinal fusion were identified. Data regarding, patient- and healthcare system-related characteristics, comorbidities, in-hospital complications, and mortality were retrieved and analyzed. In-hospital outcomes were compared between patients with or without SOT and analyzed with the use of multivariate logistic regression., Results: A total of 5984 patients with SOT underwent spinal fusion in the United States during the last decade. From 2000 to 2009, population growth-adjusted incidence of patients with SOT who underwent spinal fusion has increased more than two fold (0.102 in 2000 to 0.236 in 2009, per 100,000, P < 0.001). Comparison between patients with or without SOT showed that patients with SOT had significantly higher overall in-hospital complication rate (22.4% vs. 9.5%) and in-hospital mortality rate (1.3% vs. 0.3%). Graft versus host disease occurred in 0.7% of patients with SOT undergoing spinal fusion. Patients with SOT had a significant higher risk of urinary and renal complications and overall in-hospital complications., Conclusion: During the last decade, the incidence of patients with SOT undergoing spinal fusion has increased in the United States. In-hospital outcomes of patients with SOT undergoing spinal fusion were inferior to those of patients without SOT., Level of Evidence: 3.

Objective: To investigate the effects of surgeon volume on inpatient morbidity after 1- and 2-level anterior cervical discectomy and fusion (ACDF)., Methods: Data from the Nationwide Inpatient Sample from 2009 were extracted. All adult patients who underwent an elective 1- or 2-level ACDF for degenerative cervical spine disease were identified. Surgeon volume was analyzed as a continuous and categorical variable: very low (<12 procedures per year), low (12-23 procedures per year), medium (24-35 procedures per year), high (36-47 procedures per year), and very high (≥48 procedures per year). A multivariate logistical regression analysis was performed to calculate the adjusted odds ratios of overall in-hospital and surgical complication occurrence in relation to surgeon volume., Results: Eleven thousand two hundred forty-nine admissions were analyzed. The overall complication rate was 4.7%, and the surgical complication rate was 1.2%. Following regression analysis, increasing surgeon volume (evaluated continuously) was independently associated with lower odds of overall complication (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.98-0.99; P < 0.001) and surgical complication development (OR, 0.98; 95% CI, 0.97-0.99; P = 0.004). Surgeons with very high volume (performing 48 or more procedures per year; 4 or more per month) showed a significant decrease in overall complications (OR, 0.58; 95% CI, 0.41-0.84; P = 0.003) and surgical complications (OR, 0.52; 95% CI, 0.25-0.99; P = 0.041) when compared to surgeons with very low volume., Conclusion: In this study, increasing surgeon volume was independently associated with significantly lower odds of perioperative complications following 1- and 2-level ACDF. Performing 4 or more procedures per month was associated with the lowest complication rate., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Kidney disease in spine surgery can be associated with serious complications., Objective: To investigate the rate of acute tubular necrosis (ATN) and surgical site infection (SSI) after lumbar fusion in patients with kidney disease., Methods: A review of the U.S. Nationwide Inpatient Sample from 2002 to 2011 was performed to identify patients who underwent lumbar fusion for degenerative spine disease or disk herniation. Four groups were established: no kidney disease, chronic kidney disease (CKD), end-stage renal disease (ESRD), and posttransplant. A multivariate analysis was performed to control for age, sex, and comorbidities., Results: A total of 268,158 patients met the criteria; 263,757 with no kidney disease (98.4%), 3576 with CKD (1.3%), 586 with ESRD (0.2%), and 239 posttransplant (0.1%). Rates of ATN were 0.1%, 2.9%, 3.6%, and 0.0% for the 4 groups, respectively (P < 0.001). Rates of SSI were 0.3%, 0.4%, 1.0%, and 0.0%, respectively (P = 0.002). After controlling for patient age, sex, and medical comorbidities, patients with CKD (odds ratio [OR], 5.42; 95% confidence interval [CI], 4.14-7.09; P < 0.001) and ESRD (OR, 6.32; 95% CI, 3.89-10.33; P < 0.001) were significantly more likely to develop ATN compared with patients without kidney disease. However, CKD (OR, 0.80; 95% CI, 0.20-3.12; P = 0.754) or ESRD (OR, 1.96; 95% CI, 0.38-10.00; P = 0.415) did not increase the risk for SSI on multivariate analysis., Discussion: The rate of ATN significantly increases based on severity of kidney disease. However, patients with transplants have ATN and SSI rates comparable with patients without kidney disease., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Study Design: A retrospective review., Objective: The aim of this study was to determine national rates of cervical spine surgery and to examine factors that underlie cost variation., Summary of Background Data: There has been an increase in the rate and cost of spinal surgery over the past decades, but there is little understanding of the drivers of cost variation at the national level., Methods: We analyzed 419,830 patients who underwent cervical spine surgery (anterior cervical fusion, posterior cervical fusion, posterior cervical decompression, combined anterior/posterior cervical fusion) for degenerative conditions in the 2001 to 2013 NIS database. We determined the rates of surgery by time and geographic region, and then created univariate and multivariate models to evaluate the effect of these factors on total hospital costs: patient age, gender, race, insurance, income, county of residence, elective versus nonelective case, length of stay, risk of mortality, severity of illness, hospital bed size, wage index, hospital type, and geographic region., Results: The most common type of cervical spine surgery was anterior fusion (80.6% of all surgeries). The national rates of all cervical spine surgery decreased slightly from 2001 to 2013 (75.34 to 72.20 per 100,000 adults), while the mean inflation-adjusted cost increased 64%, from $11,799 to $19,379, during this time period. Multivariate analyses showed that older age, male gender, black/other race, private insurance, greater risk of mortality/severity of illness, and longer length of stay were associated with higher costs. The wage index was positively correlated with cost, and hospitals in the western U.S. were 27% more expensive than those in the Northeast., Conclusion: The rate of cervical spine surgery decreased slightly, while the mean case cost increased at a rate double that of inflation from 2001 to 2013. Even after controlling for patient and hospital factors including wage index, there was significant geographic variation in the cost for cervical spine surgery., Level of Evidence: 3.

Study Design: A retrospective database study., Objective: The goal of this study was to (1) evaluate the trends in the use of electromyography (EMG) for instrumented posterolateral lumbar fusions (PLFs) in the United States and (2) assess the risk of neurological injury following PLFs with and without EMG., Summary of Background Data: Neurologic injuries from iatrogenic pedicle wall breaches during screw placement are known complications of PLFs. The routine use of intraoperative neuromonitoring (ION) such as EMG during PLF to improve the accuracy and safety of pedicle screw implantation remains controversial., Methods: A retrospective review was performed using the PearlDiver Database to identify patients who had PLF surgery with and without EMG for lumbar disorders from years 2007 to 2015. Patients undergoing concomitant interbody fusions or spinal deformity surgery were excluded. Demographic trends and risk of neurological injuries were assessed., Results: During the study period, 2007 to 2015, 9957 patients underwent PLFs. Overall, EMG was used in 2495 (25.1%) of these patients. There was a steady increase in the use of EMG from 14.9% in 2007 to 28.7% in 2009, followed by a steady decrease to 21.9% in 2015 (P < 0.0001). The risk of postoperative neurological injuries following PLFs was 1.35% (134/9957) with a risk of 1.36% (34/2495) with EMG and 1.34% (100/7462) without EMG (P = 0.932). EMG is used most commonly for PLFs in the Southern part of the United States., Conclusion: In this retrospective national database review, we found that there was a steady increase in the routine use of EMG for PLFs followed by a steady decline. Regional differences were observed in the utility of EMG for PLFs. The risk of neurological complications following PLF in the absence of spinal deformity is low and the routine use of EMG for PLF may not decrease the risk., Level of Evidence: 4.

The relationship between smoking and the risk of postoperative complications among anterior cervical discectomy and fusion (ACDF) patients remains uncertain. We compared the postoperative complication rates following ACDF surgery among non-smokers, current smokers, and ever-smokers. Baseline and outcome data were obtained from the 2005- to 2014 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for patients over the age of 18 who underwent non-emergent ACDF surgery. Information on current smoking and ever-smoking status was extracted. Outcomes included development of at least one complication, development of a major complication, in-hospital mortality, and length of stay. ACDF patients were either current smokers (7847, 30.3%) or not current smokers (18,022, 69.7%); 33.0% of all patients (n=8542) had ever smoked. Current smoking status was not associated with increased odds of any one complication (P=0.584) or any major complication (P=0.138). In addition, using the number of pack-years as the primary independent variable, multivariate logistic regression analysis revealed that the number of pack-years was not significantly associated with greater odds of developing any one complication (P=0.276) or any major complication (P=0.334). However, ever-smoker status did present significantly higher odds of any major complication (OR, 1.333; 95% CI 1.007-1.764; P=0.044) than for non-smokers. These results suggest that any patient with a prior smoking history should be considered a higher risk surgical candidate when attempting ACDF., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Anterior lumbar interbody fusion (ALIF) represents a common interbody fusion technique and is advantageous given reduced risk of damage to the paraspinal muscles, posterior ligaments, and neural elements. In this study, we identified the readmission rate, common causes, and risk factors associated with single level ALIF 30-day readmission. Patients who underwent elective single level ALIF surgery from 2011 to 2013 were identified in the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database. Segmental fusion, emergency, and trauma cases were excluded. A total of 2,042 patients were identified from the ACS-NSQIP database from 2011 to 2013. The proportion of patients readmitted was 5.19% (106/2,042) and approximately 59.81% (64/106) had a reportable cause. The top three causes were poor post-operative pain control (11%), deep (9%) and superficial (9%) surgical site infections. Risk factors associated with 30-day readmission included age (odds ratio (OR)=1.02, 95% confidence interval (CI): 1.00-1.03, p value=0.05), history of severe chronic obstructive pulmonary disease (COPD), (OR=2.11, 95% CI: 0.95-4.70, p value=0.08), post-operative pneumonia (OR=6.58, 95% CI: 2.36-18.30, p value<0.001), and presence of superficial surgical site infection (OR=11.68, 95% CI: 4.88-27.95, p value<0.001). Bleeding disorders, anemia, and perioperative blood loss was not associated with 30-day readmission. Limitations include retrospective level 3 data, and missing data. This study represents the first nation-wide descriptive evaluation of 30-day readmission causes and risk factors for patients undergoing an ALIF procedure., (Copyright © 2016. Published by Elsevier Ltd.)

Study Design: An analysis of the State Inpatient Database of North Carolina, 2005 to 2012, and the Nationwide Inpatient Sample, including all inpatient lumbar fusion admissions from nonfederal hospitals., Objective: The aim of the study was to examine the influence of a major commercial policy change that restricted lumbar fusion for certain indications and to forecast the potential impact if the policy were adopted nationally., Summary of Background Data: Few studies have examined the effects of recent changes in commercial coverage policies that restrict the use of lumbar fusion., Methods: We included adults undergoing elective lumbar fusion or re-fusion operations in North Carolina. We aggregated data into a monthly time series to report changes in the rates and volume of lumbar fusion operations for disc herniation or degeneration, spinal stenosis, spondylolisthesis, or revision fusions. Time series regression models were used to test for significant changes in the use of fusion operation following a major commercial coverage policy change initiated on January 1, 2011., Results: There was a substantial decline in the use of lumbar fusion for disc herniation or degeneration following the policy change on January 1, 2011. Overall rates of elective lumbar fusion operations in North Carolina (per 100,000 residents) increased from 103.2 in 2005 to 120.4 in 2009, before declining to 101.9 by 2012. The population rate (per 100,000 residents) of fusion among those under age 65 increased from 89.5 in 2005 to 101.2 in 2009, followed by a sharp decline to 76.8 by 2012. There was no acceleration in the already increasing rate of fusion for spinal stenosis, spondylolisthesis, or revision procedures, but there was a coincident increase in decompression without fusion., Conclusion: This commercial insurance policy change had its intended effect of reducing fusion operations for indications with less evidence of effectiveness without changing rates for other indications or resulting in an overall reduction in spine surgery. Nevertheless, broader adoption of the policy could significantly reduce the national rates of fusion operations and associated costs., Level of Evidence: 3.

Objective: Anterior lumbar interbody fusion (ALIF) is a common procedure used to treat various lumbar degenerative pathologies. The purpose of this study is to describe 30-day postoperative outcomes following ALIF on a national scale., Methods: The American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) was searched for ALIF patients between 2005 and 2011. The top preoperative diagnoses were determined using ICD-9 codes. All available 30-day complications were grouped as overall composite morbidity and were compared between preoperative diagnosis groups by univariable and multivariable analyses., Results: There were a total of 1352 ALIF patients. Overall, 6.73% of patients experienced a postoperative complication. Unplanned reoperations (2.48%), urinary tract infection (1.55%), superficial surgical site infection (1.41%), and sepsis (1.11%) were the most common morbidity events. The morbidity rates for each sub-group were: intervertebral disc degeneration (4.41%), spondylosis (6.72%), lumbosacral spinal stenosis(8.21%), and spondylolisthesis (8.41%). After extensive adjustment for patient characteristics and preoperative morbidities, multivariable analysis revealed spondylolisthesis (OR=3.29; 95% CI:1.04-10.46) and spinal stenosis (OR=3.76; 95% CI:1.33-10.63) to be associated with significantly higher overall morbidity odds when compared with lumbar disc degeneration. Lumbosacral spondylosis was associated with similar outcomes as degenerative disc disease (OR =1.70; 95% CI:0.48-6.06)., Conclusions: Diverse postoperative complications need to be managed following ALIF. Patients with spondylolisthesis and spinal stenosis may carry increased 30-day postoperative morbidity profiles in ALIF when compared to those with degenerative disc disease. Prospective studies are needed to better delineate the outcomes of ALIF procedures, particularly in the spondylolisthesis and spinal stenosis patient populations., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Study Design: Multicenter retrospective cohort study., Objective: To investigate the relationship between resident involvement in the operating room and 30-day complication rates in patients undergoing single-level anterior cervical diskectomy and fusion (ACDF)., Summary of Background Data: Although an integral part of academic medicine, surgical resident participation in the operating room and its impact on patient outcomes have been a topic of debate. No large-scale study has been performed to examine this relationship in ACDF., Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was retrospectively reviewed to identify all patients who underwent single-level ACDF procedures during 2006-2013. A propensity score-matching algorithm was employed to minimize baseline differences. Multivariate logistic regression analysis of unadjusted and propensity-matched cohorts was performed to examine the effect of resident participation on 30-day postoperative complication rates and length of hospital stay., Results: A total of 3265 patients met inclusion criteria. The propensity score-matching procedure yielded 1003 pairs of well-matched nonresident and resident pairs. The multivariate analysis of propensity score-matched population demonstrated that resident involvement was not associated with an increased risk for any of the complications analyzed, including overall complications, medical complications, surgical complications, mortality, cardiac arrest, deep venous thrombosis, or length of total hospital stay., Conclusion: This large-scale, population-based study found that surgical resident participation in the operating room did not increase the risk of 30-day complications nor prolonged the length of hospital stay. Resident participation, however, was associated with an increased operative duration. Strategies to improve residents' technical proficiency outside of the operating room may enhance patient safety., Level of Evidence: 3.

Study Design: Retrospective propensity score-matched analysis on a national database (MarketScan) between 2006 and 2010., Objective: To compare rates of neurological deficits after elective single-level spinal procedures with and without intraoperative neuromonitoring, as well as associated payment differences and geographic variance., Summary of Background Data: Intraoperative neurophysiologic monitoring is a technique that may contribute to avoiding permanent neurological injury during some spine surgery procedures. However, it is unclear whether all patients undergoing spine surgery benefit from neuromonitoring., Methods: An identified 85,640 patients underwent single-level spinal procedures including anterior cervical discectomy and fusion (ACDF), lumbar fusion, lumbar laminectomy, or lumbar discectomy. Neuromonitoring was identified with appropriate Current Procedural Terminology (CPT) codes. Cohorts were balanced on baseline comorbidities and procedure characteristics using propensity score matching. Trauma and spinal tumors cases were excluded., Results: Patients (12.66%) received neuromonitoring intraoperatively. Lumbar laminectomies had reduced 30-day neurological complication rate with neuromonitoring (0.0% vs. 1.18%, P=0.002). Neuromonitoring did not correlate with reduced intraoperative neurological complications in ACDFs (0.09% vs. 0.13%), lumbar fusions (0.32% vs. 0.58%), or lumbar discectomy (1.24% vs. 0.91%). With the addition of neuromonitoring, payments for ACDFs increased 16.24% ($3842), lumbar fusions 7.84% ($3540), lumbar laminectomies 24.33% ($3704), and lumbar discectomies 22.54% ($2859). Significant geographic variation was evident. Some states had no recorded single-level spinal cases with concurrent neuromonitoring. Rates for ACDFs and lumbar fusions, laminectomies, and discectomies ranged as high as 61%, 58%, 22%, and 21%, respectively., Conclusion: With intraoperative neurological monitoring in single-level procedures, neurological complications were decreased only among lumbar laminectomies. No difference was observed in ACDFs, lumbar fusions, or lumbar discectomies. There was a significant increase in total payments associated with the index procedure and hospitalization. We demonstrate significant geographic variation in neuromonitoring., Level of Evidence: 3.

Study Design: Epidemiologic study., Objective: To compare the utilization of anterior cervical discectomy and fusion (ACDF) versus cervical disc arthroplasty (CDA) in terms of patient and hospital characteristics during the 3 years after Food and Drug Administration (FDA) approval of CDA devices in 2007., Summary of Background Data: There was a surge in CDA adoption in the 3 years prior to FDA approval of CDA devices in 2007. However, utilization trends of CDA versus ACDF since the FDA approval are unknown., Methods: The Nationwide Inpatient Sample database was used to identify CDA and ACDF procedures performed in the United States in the 3 years after FDA approval of CDA devices (2008-2010). The frequencies of CDA and ACDF were estimated, stratified by patient and hospital characteristics. Average length of hospital stay and total charges and costs were estimated. Multivariable analysis was performed to identify patient and hospital characteristics associated with CDA utilization., Results: In the 3 years after FDA approval of cervical disc devices, population-adjusted growth rates for CDA and ACDF were 4.9% and 11.8%, respectively (P = 0.6977). Female, African American and Medicaid patients were less likely to receive CDA. CDA was less likely to be performed in patients with cervical spondylotic changes and more likely to be performed in younger and healthier patients. CDA was less likely to be performed in the Midwestern United States or in public hospitals., Conclusion: The prevalence of CDA increased in the 3 years after FDA approval with a growth rate that is approximately twice than that for ACDF. Although there seems to be CDA adoption, CDA growth seemed to have reached a plateau and ACDF still remained the dominant surgical strategy for cervical disc disease. Possible regional, racial, and sex disparities in CDA utilization and a more strict approach in the selection of CDA over traditional ACDF may have impeded rapid adoption of CDA., Level of Evidence: 3.

Study Design: Retrospective database analysis., Objective: To compare perioperative patient characteristics, hospital resource utilization, and early postoperative outcomes in patients requiring reintubation after anterior cervical fusion (ACF)., Summary of Background Data: Airway compromise is a potential complication after anterior cervical surgery. Postsurgical soft-tissue edema or hematoma formation may be so severe that an unplanned reintubation may be required. The rate of reintubation after ACF and the effect on hospital outcomes remains unknown., Methods: The Nationwide Inpatient Sample database was queried from 2002-2011. Patients undergoing elective ACF procedures for degenerative diagnoses were selected. Those who required an unplanned reintubation after ACF were identified. Patient demographics, comorbidities, length of stay, costs, number of levels fused, and mortality were analyzed. SPSS version 20 was used for statistical analysis and a P < 0.001 denoted statistical significance., Results: A total of 262,425 patients underwent an elective ACF between 2002 and 2011 of which 1464 patients (5.6 per 1000 cases) required reintubation during their admission. The rate of reintubation was statistically greater for 3+-level fusions than the 1- to 2-level fusion cases. On average, patients requiring reintubation were older and had a greater number of comorbidities. These patients also incurred a significantly greater hospital stay and total hospital costs than unaffected patients. In addition, significant predictors for reintubation included 3+-level fusions, congestive heart failure, anemia, postoperative aspiration pneumonia, hematoma, thromboembolic events, and dysphagia., Conclusion: The reintubation rate after an elective ACF is 0.5%, and it increases to 1.6% after 3+-level fusions. Older patients with greater comorbidities are at an increased risk for reintubation. Given the greater LOS, costs and mortality associated with reintubation, it is imperative to identify patients at increased risk to help improve patient outcomes and decrease hospital resource utilization., Level of Evidence: 4.

Study Design: Retrospective database analysis., Objective: To determine rates of gastrointestinal (GI) hemorrhage after lumbar fusions, a population-based database was analyzed to identify incidence, mortality, and risk factors associated with anterior (ALF), posterior (PLF), and simultaneous anterior/posterior (APLF) lumbar fusions., Summary of Background Data: GI hemorrhage after lumbar surgery is a rare complication that can have devastating consequences. Incidences of GI bleeding after lumbar fusion are not well characterized in the current literature., Methods: Data from the Nationwide Inpatient Sample were obtained from 2002 to 2009. Patients undergoing ALF, PLF, and APLF for degenerative pathologies were identified and the incidence of GI hemorrhage was evaluated. Patient demographics, Charlson Comorbidity Index, length of stay, costs, and mortality were assessed. SPSS version 20 (IBM; Armonk, NY) was used to detect statistical differences between groups and perform logistic regression analyses to identify independent predictors of GI bleeding. A P value of <0.001 denoted significance., Results: A total of 220,522 lumbar fusions were identified in the United States from 2002 to 2009. Of these, 19,762 were ALFs, 182,801 were PLFs, and 17,959 were APLFs. GI bleeding was noted in ALFs, with 1.1 events per 1000 cases, PLFs with 1.4 events, and APLFs with 1.7 events. Patients with GI bleeding demonstrated greater Charlson Comorbidity Index scores, length of stay, costs, and mortality (P < 0.001). Logistic regression analysis demonstrated independent predictors of GI hemorrhage including advanced age (>65 yr), male sex, blood loss anemia, fluid/electrolyte disorders, metastatic neoplasm, and weight loss (P < 0.001)., Conclusion: The results of our study demonstrate very low complication rates of GI hemorrhage across ALFs, PLFs, and APLF cohorts. Across all surgical procedures, the presence of GI bleeding complications was associated with greater comorbidity, length of stay, cost, and mortality. We strongly advise physicians to perform stringent perioperative assessments of risk factors and to provide prompt medical attention to minimize the impact of GI bleeding complications., Level of Evidence: 3.