Search

Tranexamic acid (TXA) has long been utilized in spine surgery and can be administered through intravenous (IV) and topical routes. Although, topical and IV administration of TXA are both effective in decreasing blood loss during spine surgery, complications like deep vein thrombosis (DVT) and pulmonary embolism have been reported with the use of intravenous TXA (ivTXA). These potential complications may be mitigated through the use of topical TXA (tTXA). To assess optimal dosing protocols and efficacy of topical TXA in spine surgery, Embase, Ovid-MEDLINE, Scopus, Cochrane, and clinicaltrials.gov were queried for original research on the use of tTXA in adult patients undergoing spine surgery. Data parameters analyzed included blood loss, transfusion rate, thromboembolic, and other complications. Data was synthesized and confidence evaluated according to the Grades of Recommendation, Assessment, Development, and Evaluation approach. Nineteen studies were included in the final analysis with 2197 patients. Of the 18 published studies, 9 (50%) displayed high levels of evidence. Topical TXA showed a trend towards a lower risk of transfusion and complications. Protocols that used 1g tTXA showed a significantly reduced risk for transfusion when compared to controls (risk ratio −1.05, 95% CI (−1.62, −0.48); P = 0.94, I2 = 0%). Complications associated with tTXA included DVTs and wound infections. Topical TXA was non-inferior to intravenous TXA with similar efficacy and complication profiles for bleeding control in spine surgery; however, more studies are needed to discern benefits and risks. [ABSTRACT FROM AUTHOR]

Introduction: Interbody fusion is commonly utilized for arthrodesis and stability among patients undergoing spine surgery. Over the last few decades, interbody device materials, such as titanium and polyetheretherketone (PEEK), have been replacing traditional autografts and allografts for interbody fusion. As such, with the exponential growth of bioengineering, a large variety cage surface technologies exist. Different combinations of cage component materials and surface modifications have been created to optimize interbody constructs for surgical use. This review aims to provide a comprehensive overview of common surface technologies, their performance in the clinical setting, and recent modifications and material combinations. Materials and Methods: We performed a comprehensive review of the literature on titanium and PEEK as medical devices between 1964 and 2021. We searched five major databases, resulting in 4974 records. Articles were screened for inclusion manually by two independent reviewers, resulting in 237 articles included for review. Conclusion: Interbody devices have rapidly evolved over the last few decades. Biomaterial and biomechanical modifications have allowed for continued design optimization. While titanium has a high osseointegrative capacity, it also has a high elastic modulus and is radio-opaque. PEEK, on the other hand, has a lower elastic modulus and is radiolucent, though PEEK has poor osseointegrative capacity. Surface modifications, material development advancements, and hybrid material devices have been utilized in search of an optimal spinal implant which maximizes the advantages and minimizes the disadvantages of each interbody material. [ABSTRACT FROM AUTHOR]

Study Design. A retrospective cohort study. Objective. To identify differences in complication rates after cervical and lumbar fusion over the first postoperative year between those with and without cannabis use disorder (CUD) and to assess how CUD affects opioid prescription patterns. Summary of Background Data. Cannabis is legal for medical purposes in 36 states and for recreational use in 18 states. Cannabis has multisystem effects and may contribute to transient vasoconstrictive, prothrombotic, and inflammatory effects. Methods. The IBM MarketScan Database (2009-2019) was used to identify patients who underwent cervical or lumbar fusions, with or without CUD. Exact match hospitalization and postdischarge outcomes were analyzed at index, six, and 12 months. Results. Of 72,024 cervical fusion (2.0% with CUD) and 105,612 lumbar fusion patients (1.5% with CUD), individuals with CUD were more likely to be young males with higher Elixhauser index. The cervical CUD group had increased neurological complications (3% vs. 2%) and sepsis (1% vs. 0%) during the index hospitalization and neurological (7% vs. 5%) and wound complications (5% vs. 3%) at 12 months. The lumbar CUD group had increased wound (8% vs. 5%) and myocardial infarction (MI) (2% vs. 1%) complications at six months and at 12 months. For those with cervical myelopathy, increased risk of pulmonary complications was observed with CUD at index hospitalization and 12-month follow-up. For those with lumbar stenosis, cardiac complications and MI were associated with CUD at index hospitalization and 12 months. CUD was associated with opiate use disorder, decreasing postoperatively. Conclusions. No differences in reoperation rates were observed for CUD groups undergoing cervical or lumbar fusion. CUD was associated with an increased risk of stroke for the cervical fusion cohort and cardiac (including MI) and pulmonary complications for lumbar fusion at index hospitalization and six and 12 months postoperatively. Opiate use disorder and decreased opiate dependence after surgery also correlated with CUD. [ABSTRACT FROM AUTHOR]

Although studies have explored acute opioid use within 30 days after surgery and chronic opioid use longer than 90 days after surgery, the impact of opioid use within the subacute phase of 31-90 days after surgery has not been studied. However, this subacute postoperative period has been identified as a potential predictor of chronic opioid use. This study aims to identify factors common in opioid-naïve patients who are at a high risk of opioid use during the subacute phase of 31-90 days after discharge. Retrospective analysis. Adult opioid-naïve patients who underwent spine surgeries at a quaternary medical care center from June 2012 to December 2019. Opioid refills in the subacute postoperative period of 31-90 days following discharge. In this retrospective cohort study, the electronic medical record of adult opioid-naïve patients who underwent spine surgeries at a quaternary medical care center from June 2012 to December 2019 were analyzed. Opioid refills in the subacute postoperative period of 31-90 days following discharge were the primary study outcome. Of the study cohort consisting of 3,024 patients, 2,685 (89%) required inpatient opioids in the last 24 hours before discharge, 733 (26%) required an opioid refill 1-30 days after discharge, and 579 (19%) required opioid refill 31-90 days after discharge. Moreover, a postoperative opioid refill 1-30 days after discharge conferred the strongest risk of an opioid refill 31-90 days after discharge (OR 4.66, 95% CI 3.84-5.64). Other factors associated with the increased risk of an opioid refill 31-90 days after discharge were gabapentinoid use, discharge disposition to facilities other than home or self-care, reoperation, and female gender. Meanwhile, Asian American race was associated with the reduced risk. Those requiring opioid refills were noted to be younger, underwent longer surgeries, had extended inpatient hospital stays, required higher doses of inpatient opioids, and required higher doses of discharge opioid prescriptions for longer durations. In opioid-naïve postoperative spine patients, opioid refills 1-30 days after discharge were strongly associated with an increased risk of opioid refills 31-90 days after discharge. Factors associated with opioid refill requirements also included longer surgeries and inpatient hospital stays as well as higher doses of inpatient opioids. Overall, this study enables physicians to identify patients at a higher risk of opioid use and to intervene early during the postoperative course. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Study Design: A retrospective review.Objective: This study aimed to determine the factors associated with malpractice litigation in cases involving spine surgery in the United States.Summary Of Background Data: Medical malpractice is of substantial interest to the medical community due to concerns of increased health care costs and medical decision-making for the sole purpose of reducing legal liability.Methods: The Westlaw online legal database (Thomson Reuters, New York, NY) was searched for verdict and settlement reports pertaining to spine surgery from 2010 to 2015. Data were collected regarding type of procedure, patient age and gender, defendant specialty, outcome, award, alleged cause of malpractice, and factors involved in the plaintiff's decision to file. Initial search queried 187 cases, after which exclusion criteria were applied to eliminate duplicates and cases unrelated to spine surgery, yielding a total of 98 cases for analysis.Results: The verdict was in favor of the defendant in 62 cases (63.3%). Neurosurgeons and orthopedic surgeons were the most common defendants in 29 (17.3%) and 40 (23.8%) of the cases, respectively. A perceived lack of informed consent was noted as a factor in 24 (24.4%) of the cases. A failure to diagnose or a failure to treat was noted in 31 (31.6%) and 32 (32.7%) cases, respectively. Median payments for plaintiff verdicts were nearly double those of settlements ($2,525,000 vs. $1,300,000). A greater incidence of plaintiff verdicts was noted in cases in which a failure to treat (P < 0.05) was cited, a patient death occurred (P < 0.05), or an emergent surgery had been performed (P < 0.01).Conclusion: Overall, physicians were not found liable in the majority of spine surgery malpractice cases queried.Level Of Evidence: 4. [ABSTRACT FROM AUTHOR]

Cross-sectional study. This study aimed to stratify the geographic distribution of academic spine surgeons in the United States, analyzing how this distribution highlights differences in academic, demographic, professional metrics, and gaps in access to spine care. Spine surgeons were identified using American Association of Neurological Surgeons and American Academy of Orthopedic Surgeons databases, categorizing into geographic regions of training and practice. Departmental websites, National Institutes of Health (NIH) RePort Expenditures and Results, Google Patent, and NIH icite databases were queried for demographic and professional metrics. Academic spine surgeons (347 neurological; 314 orthopedic) are predominantly male (95%) and few have patents (23%) or NIH funding (4%). Regionally, the Northeast has the highest proportion per capita (3.28 surgeons per million), but California is the state with the highest proportion (13%). The Northeast has the greatest regional retention post-residency at 74%, followed by the Midwest (59%). The West and South are more associated with additional degrees. Neurosurgery-trained surgeons hold more additional degrees (17%) than orthopedic surgeons (8%), whereas more orthopedic surgeons hold leadership positions (34%) than neurosurgeons (20%). Academic spine surgeons are found at the highest proportion in the Northeast and California; the Northeast has the greatest regional retention. Spine neurosurgeons have more additional degrees, whereas spine orthopedic surgeons have more leadership positions. These results are relevant to training programs looking to correct geographic disparities, surgeons in search of training programs, or students in pursuit of spine surgery. [ABSTRACT FROM AUTHOR]

• Patients with cervical spine disease suffer from upper limb functional impairment. • No clinical benchmarks exist that define meaningful improvement in the upper limb function following cervical spine surgery. • Disabilities of arm, shoulder, and hand (DASH) is a validated outcome measure indicating upper limb disability. • This study aimed to establish minimal clinical important difference (MCID) and substantial clinical benefit (SCB) of the DASH score following cervical spine surgery. • The MCID of the DASH was –8 points and the SCB was –18 points. These metrics can be used to evaluate minimal and substantial improvement in the upper limb function following cervical spine surgery. Patients with cervical spine disease suffer from upper limb disability. At present, no clinical benchmarks exist for clinically meaningful change in the upper limb function following cervical spine surgery. Primary: to establish clinically meaningful metrics; the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) of upper limb functional improvement in patients following cervical spine surgery. Secondary: to identify the prognostic factors of MCID and SCB of upper limb function following cervical spine surgery. Retrospective cohort study. Adult patients ≥18 years of age who underwent cervical spine surgery from 2012 to 2016. Patient-reported outcomes: Neck disability index (NDI) and Disabilities of Arm, Shoulder, and Hand (DASH). MCID was defined as minimal improvement and SCB as substantial improvement in the DASH score at last follow-up. The anchor-based methods (ROC analyses) defined optimal MCID and SCB thresholds with area under curve (AUC) in discriminating improved vs. non-improved patients. The MCID was also calculated by distribution-based methods: half standard-deviation (0.5-SD) and standard error of the mean (SEM) method. A multivariable logistic regression evaluated the impact of baseline factors in achieving the MCID and SCB in DASH following cervical spine surgery. Between 2012 and 2016, 1,046 patients with average age of 57±11.3 years, 53% males, underwent cervical spine surgery. Using the ROC analysis, the threshold for MCID was –8 points with AUC of 0.73 (95% CI: 0.67–0.79) and the SCB was –18 points with AUC of 0.88 (95% confidence interval [CI]: 0.85–0.91). The MCID was –11 points by 0.5–SD and –12 points by SEM-method. On multivariable analysis, patients with myelopathy had lower odds of achieving MCID and SCB, whereas older patients and those with ≥6 months duration of symptoms had lower odds of achieving DASH MCID and SCB respectively. In patients undergoing cervical spine surgery, MCID of –8 points and SCB of –18 points in DASH improvement may be considered clinically significant. These metrics may enable evaluation of minimal and substantial improvement in the upper extremity function following cervical spine surgery. [ABSTRACT FROM AUTHOR]

As surgical techniques for deformity correction evolve towards minimizing tissue trauma, further clarity is warranted to define differences in complication profiles between cMIS and open surgeries. To compare cMIS and open surgery reoperation rates and identify contributing etiologies to reoperation in each cohort. Prospective multicenter observational series. Database enrollment required age =18 years, adult spinal deformity and circumferential minimally invasive spine surgery. Reoperation rate, patient reported outcomes (PROMS), spinopelvic parameters, mechanical failures (defined as rod breakage/dislocation, screw breakage/loosening, set screw loosening, proximal/distal junctional kyphosis, pseudoarthrosis) and other factors contributing to re-operation such as wound infection, medial breach, nerve impingement by screw, vertebral body fracture, sagittal/coronal imbalance, and wound infection. A total of 85 patients (pts) with cMIS for ASD with 2-year follow-up (2YFU) were identified and propensity matched to 85 patients in open cohort. Propensity matching was performed based on pre-operative PT, PI-LL, BMI, and SVA. Patient demographic variables, reoperation rate, and complications contributing to reoperation were compared with uni- and multi-variate analysis at any time in each cohort (33 open, 17 cMIS). PROMS at 2YFU were compared in the reoperated cohorts. Total of 33 reoperation in the open cohort vs 17 in cMIS were identified. The reoperation rate was significantly higher in the open cohort at 39% (33/85) compared to 20% (17/85) in the cMIS cohort (P= 0.012). The reoperation rate in open cohort related to mechanical failure was 52% (17/33) compared to 35% (6/17) in cMIS cohort (P= 0.43). No significant difference was found in rates of specific etiologies contributing to complications in the cMIS vs open reoperation cohorts under uni- and multivariate analysis. The change in spinopelvic parameters among the two reoperation cohorts at 2YFU were statistically not significant (δCVA, δSVA, δPI-LL, δPT, δLL CA, δTL CA). Under univariate analysis, the following PROMS were similar: ODI, NRS Leg and Back Pain, EQ5D, EQ5D-VAS, SF-36 PCS,SF-36 MCS. However, SRS-22 in open cohort was significantly higher at 2YFU (3.55 ± 0.73 open vs. 3,10 ± 0.56 MIS, p = 0.029). Findings in our ongoing study show that cMIS procedures were associated with a significantly lower reoperation rate compared to open surgical approaches. PROMS and the change in spinopelvic parameters were similar at 2YFU in both reoperated cohorts (except for SRS-22 favored open cohort). This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Study Design: Bibliometric analysis.Objective: To apply the established technique of citation analysis to identify the 100 most influential articles in scoliosis surgery research published between 1900 and 2015.Summary Of Background Data: Previous studies have applied the technique of citation analysis to other areas of study. This is the first article to apply this technique to the field of scoliosis surgery.Methods: A two-step search of the Thomson Reuters Web of Science was conducted to identify all articles relevant to the field of scoliosis surgery. The top 100 articles with the most citations were identified based on analysis of titles and abstracts. Further statistical analysis was conducted to determine whether measures of author reputation and overall publication influence affected the rate at which publications were recognized and incorporated by other researchers in the field.Results: Total citations for the final 100 publications included in the list ranged from 82 to 509. The period for publication ranged from 1954 to 2010. Most studies were published in the journal Spine (n = 63). The most frequently published topics of study were surgical techniques (n = 35) and outcomes (n = 35). Measures of author reputation (number of total studies in the top 100, number of first-author studies in the top 100) were found to have no effect on the rate at which studies were adopted by other researchers (number of years until first citation, and number of years until maximum citations). The number of citations/year a publication received was found to be negatively correlated with the rate at which it was adopted by other researchers, indicating that more influential manuscripts attained more rapid recognition by the scientific community at large.Conclusion: In assembling this publication, we have strived to identify and recognize the 100 most influential articles in scoliosis surgery research from 1900 to 2015.Level Of Evidence: N/A. [ABSTRACT FROM AUTHOR]

It remains unclear how type of insurance coverage affects long-term, spine-specific patient-reported outcomes (PROs). This study sought to elucidate the impact of insurance on clinical outcomes after lumbar spondylolisthesis surgery. The prospective Quality Outcomes Database registry was queried for patients with grade 1 degenerative lumbar spondylolisthesis who underwent single-segment surgery. Twenty-four-month PROs were compared and included Oswestry Disability Index, Numeric Rating Scale (NRS) back pain, NRS leg pain, EuroQol-5D, and North American Spine Society Satisfaction. A total of 608 patients undergoing surgery for grade 1 degenerative lumbar spondylolisthesis (mean age, 62.5 ± 11.5 years and 59.2% women) were selected. Insurance types included private insurance (n = 319; 52.5%), Medicare (n = 235; 38.7%), Medicaid (n = 36; 5.9%), and Veterans Affairs (VA)/government (n = 17; 2.8%). One patient (0.2%) was uninsured and was removed from the analyses. Regardless of insurance status, compared to baseline, all 4 cohorts improved significantly regarding ODI, NRS-BP, NRS-LP, and EQ-5D scores (P < 0.001). In adjusted multivariable analyses, compared with patients with private insurance, Medicaid was associated with worse 24-month postoperative Oswestry Disability Index (β = 10.2; 95% confidence interval [CI], 3.9–16.5; P = 0.002) and NRS leg pain (β =1.3; 95% CI, 0.3–2.4; P = 0.02). Medicaid was associated with worse EuroQol-5D scores compared with private insurance (β = −0.07; 95% CI −0.01 to −0.14; P = 0.03), but not compared with Medicare and VA/government insurance (P > 0.05). Medicaid was associated with lower odds of reaching ODI minimal clinically important difference (odds ratio, 0.2; 95% CI, 0.03–0.7; P = 0.02) compared with VA/government insurance. NRS back pain and North American Spine Society satisfaction did not differ by insurance coverage (P > 0.05). Despite adjusting for potential confounding variables, Medicaid coverage was independently associated with worse 24-month PROs after lumbar spondylolisthesis surgery compared with other payer types. Although all improved postoperatively, those with Medicaid coverage had relatively inferior improvements. [ABSTRACT FROM AUTHOR]

In potentially unstable and unstable patients with metastatic spinal tumor with Spinal Instability Neoplastic Scores (SINS) 7-12 and > 12, it is unclear if surgery improves Karnofsky Performance Score (KPS). To determine if patients with SINS 7-12 and > 12 will benefit from surgery and have improvement in their KPS score postoperatively. Retrospective, single center. Patients > 18 years old, metastatic spinal tumor, with preoperative SINS 7-12 and > 12. Change in KPS score post-operatively to assess for functional status. Total of 132 patients with metastatic spinal tumor with SINS 7-12 (N: 66) and SINS > 12 (N:66) were retrospectively reviewed with pre- and postoperative KPS. Baseline clinical characteristics including age, sex, SINS score, Bilsky compression grade, neurologic function and preoperative KPS were collected; 27/132 patients preoperatively had radiation with N: 12 in SINS 7-12 cohort and N:15 in SINS > 12. KPS scores were obtained preradiation, postradiation, preoperatively, and postoperatively. Paired, nonparametric Wilcoxon signed-rank test was used to determine significance of improvement in KPS after surgery. Ordinal logistic regression was used to identify factors associated with the change in KPS. In SINS 7-12 cohort (N:66), the median SINS score was 11 with a mean followup of 3.7 years and median followup of 2.85 years. Followup ranged from 1 month to 13 years. The survival rate was 94% at 1-year, 88% at 2-year, and 82% at 3-year. In SINS > 12 cohort (N:66), the median SINS score was 14 with a mean followup of 2.19 years. The survival rate was 85% at 1-year, 82% at 2-year and 74% at 3-year. In this cohort, postoperatively significant improvement in KPS occurred from a median of 50 to 70 (p = 0.0003). In patients who did not receive radiation preoperatively, Wilcox test showed significant improvement in KPS postoperatively (P=0.006). In patients who received radiation preoperatively, there was not any improvement in the KPS. Ordinal logistic regression showed that after surgery, patients were more likely to have higher KPS scores (ie, 70-90). This improvement in KPS was observed independent of the preoperative Bilsky grade. Further, KPS was not associated with ASIA motor improvement on univariate ordinal logistic regression and this effect was maintained after controlling for Bilsky cord compression grade on multivariate models. In SINS > 12 cohort, postoperatively significant improvement in KPS occurred from a median of 50 to 60 (p = 0.001, Wilcoxon signed-rank test). On ordinal logistic regression, Bilsky compression grade as well as ASIA motor did not predict the degree of KPS improvement. Nevertheless, patients with a preoperative Bilsky compression grade 3 had a statistically significant improvement in KPS (p = 0.001), while patients with grade 2 did not (p = 0.22). Surgical intervention can improve patient functional outcome with metastatic spinal tumor with SINS 7-12 and SINS > 12 as assessed by the change in their KPS postoperatively. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]