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OBJECTIVE Spinal osteomyelitis and spondylodiscitis (SD) are infections of the vertebral body and disc, respectively, with more than 50% associated with Staphylococcus aureus. Methicillin-resistant S. aureus (MRSA) has become a pathogen of interest in cases of SD due to increasing prevalence. The purpose of this investigation was to characterize the current epidemiological and microbiological landscape in SD cases, in addition to medical and surgical challenges in treating these infections. METHODS The PearlDiver Mariner database was queried for ICD-10 codes to identify cases of SD from 2015 to 2021. The initial cohort was stratified by offending pathogens, including methicillin-sensitive S. aureus (MSSA) and MRSA. Primary outcome measures included epidemiological trends, demographics, and rates of surgical management. Secondary outcomes included length of hospital stay, rate of reoperation, and complications associated with surgical cases. Multivariable logistic regression was used to control for age, gender, region, and Charlson Comorbidity Index (CCI). RESULTS Nine thousand nine hundred eighty-three patients met the inclusion criteria and were retained for this study. Approximately half (45.5%) of SD cases resulting from S. aureus infections each year were resistant to beta-lactam antibiotics. The proportion of cases that were managed surgically was 31.02%. Among the cases that involved surgical intervention, 21.83% underwent revision operations within 30 days of the original procedure and 37.29% of cases returned to the operating room within 1 year. Substance abuse, specifically alcohol, tobacco, and drug use, were strong predictors for surgical intervention in cases of SD (all p < 0.001), in addition to obesity (p = 0.002), liver disease (p < 0.001), and valvular disease (p = 0.025). After adjusting for age, gender, region, and CCI, cases of MRSA were more likely to undergo surgical management (OR 1.19, p = 0.003). MRSA SD also exhibited higher rates of reoperation within 6 months (OR 1.29, p = 0.001) and 1 year (OR 1.36, p < 0.001). Surgical cases resulting from MRSA infections also exhibited higher morbidity and significant rates of transfusion (OR 1.47, p = 0.030), acute kidney injury (OR 1.35, p = 0.001), pulmonary embolism (OR 1.44, p = 0.030), pneumonia (OR 1.49, p = 0.002), and urinary tract infection (OR 1.45, p = 0.002) compared with MSSA SD infections. CONCLUSIONS More than 45% of cases of S. aureus SD in the US are resistant to beta-lactam antibiotics, presenting obstacles in treatment. Cases of MRSA SD are more likely to be managed surgically and have higher rates of complications and reoperations. Early detection and prompt operative management are imperative to reduce the risk of complications.

Sarcopenia, characterized by decreased muscle mass and function, is projected to affect more than 200 million people worldwide by 2060. This study aimed to evaluate the rates of short-term complications following lumbar spine arthrodesis in patients with and without a recent diagnosis of sarcopenia.The PearlDiver database was queried to evaluate all patients who underwent index lumbar spine arthrodesis from 2012 to 2019. Multivariate logistic regression was used to compare rates of 90-day surgical and medical complications. Kaplan-Meier analysis was performed to compare cumulative rates of reoperation and all-cause hospital readmission. Two sample t testing was used to compare costs of care. Statistical significance was set at P0.05 a priori.Of 239,953 patients undergoing lumbar spine arthrodesis, 1087 had a recent diagnosis of sarcopenia (0.45%) before surgery. Patients with sarcopenia were significantly more likely to experience a urinary tract infection (odds ratio = 1.41, P = 0.035) and undergo incision and drainage (odds ratio = 2.66, P = 0.010) within 90 days after lumbar arthrodesis. Patients with sarcopeniawere at a 24% greater risk of 1-year all-cause hospital readmission. The 90-day cost of care was significantly greater in patients with sarcopenia ($37,689.86 vs. $26,635.72; P 0.001).In patients undergoing lumbar spine arthrodesis, sarcopenia is associated with an increased risk of postoperative complications, including increased costs of care. Spine surgeons should consider screening patients for sarcopenia preoperatively and counsel them regarding their increased risk of complications. Additionally, surgeons may consider preoperative optimization, like the management of low bone density.

Previous studies have demonstrated that obesity is associated with increased complications after lumbar fusion. However, there are little published data on the effect of being underweight on lumbar fusion outcomes. The purpose of this study was to elucidate the effect of being underweight versus obese on outcomes after lumbar spinal fusion.Lumbar spinal fusion patients were identified through the PearlDiver Mariner database between 2010 and 2020. Study groups were created using International Classification of Diseases codes to identify preoperative body mass index (BMI) category as morbid obesity (BMI40), obesity (BMI 30 to 40), normal BMI (BMI 20 to 30), and underweight (BMI20) cohorts. Complications that occurred within 1 year postoperatively in this study and matched control groups were then isolated. Statistical analyses were conducted using the Pearson chi square method.A total of 62,616 patients were identified in this analysis. This included 1,258 underweight patients (4.0%), 17,996 obese patients (57.5%), and 12,054 morbidly obese patients (38.5%). The number of patients to experience any postoperative complication was 766 (60.9%), 9,440 (52.4%), and 6,982 (57.9%) for the underweight, obese, and morbidly obese cohorts, respectively. Underweight patients showed an increased likelihood of complications related to instrumentation (odds ratio [OR] 1.85, P = 0.0237), revision fusion (OR 1.34, P = 0.04061), pulmonary complications (OR 1.43, P0.001), and sepsis (OR 1.91, P0.001). Obese patients with BMI 30 to 40 showed increased odds of the following complications: hemorrhages and hematomas (OR 1.20, P = 0.02634), surgical site complications (OR 1.27, P0.001), thromboembolism (OR 1.78, P0.001), and urinary complications (OR 1.08, P0.001). Morbidly obese patients with BMI40 showed increased odds of all complications analyzed in this study.This investigation indicates that both underweight and obese patients are at elevated risk of complications after lumbar fusion. Similar to obese patients, underweight patients may benefit from preoperative optimization by nutrition counseling to avoid potential complications.III.

Previous studies identified a correlation between preoperative resilience scores and patient reported outcome measures in several surgical subspecialities. No previous studies, to our knowledge, have analyzed preoperative resilience and patient reported outcomes in lumbar spinal fusion.Patients undergoing lumbar spinal fusion completed the Brief Resilience Scale (BRS) preoperatively, in addition to measures of disability (Oswestry Disability index [ODI]), quality of life (PROMIS global physical and mental health scales and EuroQol5), and leg and back pain (VAS) at pre- and 3-months postoperatively. The 3-month follow-up was selected due to the association with return to work. Multiple linear regression evaluated relationships between resilience and postoperative changes in outcomes measures, controlling for baseline values and body mass index, age, number of levels fused, and severity of comorbidities.Ninety-five participants (mean age 58 years, 56% male) completed the BRS preoperatively and outcome measures before and 3 months after lumbar fusion. On average, participants reported significant postoperative improvements on all outcome measures (P0.001). Higher preoperative resilience scores related to greater postoperative improvements in back and leg pain, global mental and physical health and EuroQol scores (P0.05), after controlling for baseline values and other covariates. Resilience scores did not significantly correlate with postoperative changes in ODI (P0.05).Preoperative resilience is associated with improvement in pain and physical and mental health quality of life during the early postoperative period following lumbar spinal fusion. Additional research is needed to determine if improvements are maintained beyond this interval and whether resilience can be modified to optimize outcomes.

The effect of malnutrition on outcomes after posterior lumbar fusion (PLF) remains understudied. This study analyzes the effect of malnutrition across a comprehensive range of body mass index (BMI) on complications after PLF.The Pearldiver Mariner database was queried between 2010 and 2020 using International Classification of Diseases (Ninth and Tenth Revisions) codes for malnutrition and Current Procedural Terminology codes for PLF. Patients were identified with preoperative BMI diagnosis codes and partitioned into one of the following BMI cohorts: underweight (BMI20), normal (BMI 19-30), obese (BMI 30-40), and morbidly obese (BMI40). An additional all-BMI cohort was created using patients with any BMI code. All cohorts were matched 1:3 to control patients within the same BMI group without malnutrition based on age, gender, and Charlson comorbidity index. Complication rates were calculated using the Pearson χThe number of patients in each cohort were 1106 (all-BMI), 227 (underweight), 808 (normal), 667 (obese), and 449 (morbidly obese). Statistical analysis showed that the all-BMI cohort had greater odds of complications related to instrumentation (odds ratio [OR]: 2.28; P0.001), need for revision fusion (OR: 2.04; P0.001), pulmonary complications (OR: 1.45; P0.001), sepsis (OR: 2.89; P0.001), surgical site complications (OR: 1.87; P 0.001), and urinary complications (OR: 1.41; P0.001). No difference was noted between the BMI-specific cohorts for complication risk.Our analysis indicates that malnutrition may independently increase PLF complication risk. Surgeons may consider preoperative optimization for malnutrition patients to reduce complication risk.

To characterize the volume dependence of both facilities and surgeons on postoperative complications after lumbar fusion and characterize the role of socioeconomic status.Adults who underwent lumbar fusion from 2011 to 2015 were identified using International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes for lumbar disc degeneration or spondylolisthesis and procedure codes for lumbar fusion in the New York Statewide Planning and Research Cooperative System database. Complications were compared across surgeon and facility volumes using multivariable Cox proportional hazards regression, controlling for patient demographic and clinical factors. Surgeon and facility volumes were compared between the lowest and highest 20%.Of the 26,211 patients identified with a lumbar fusion, 16,377 patients were treated at a high-volume or low-volume facility or by a high-volume or low-volume surgeon. Low-volume facilities had higher 3-month and 12-month rates of readmission, pneumonia, and cellulitis; lower 1-month, 3-month, and 12-month rates of deep vein thrombosis; and lower 1-month rates of wound complications. Low-volume surgeons had higher 1-month, 3-month, and 12-month rates of readmission, acute renal failure, surgical site infection, and wound complications; high 1-month and 3-month rates of urinary tract infection and pulmonary embolism; and a lower 12-month rate of revision. Patients who were treated by low-volume surgeons and had complications were more concentrated to ZIP codes with high social deprivation.Both high-volume facilities and high-volume surgeons show lower rates of complications and readmission. There are significant socioeconomic disparities regarding which patients can access high-volume surgeons.

Cervical myelopathy is a clinical syndrome caused by compression of the spinal cord between the levels of the C1 and T1 vertebrae. Its clinical presentation can mimic many other degenerative and neurological pathologies, making diagnosis challenging. Diagnosis is confirmed with appropriate imaging studies carefully correlated with history and physical examination. Treatment options are focused on decompression of the spinal canal from an anterior, posterior, or combined anterior and posterior surgical approach depending on the location of compression and patient factors. Outcomes are favorable if treatment is performed prior to severe symptom onset.

Few studies have evaluated the utility of machine learning techniques to predict and classify outcomes, such as length of stay (LOS), for lumbar fusion patients. Six supervised machine learning algorithms may be able to predict and classify whether a patient will experience a short or long hospital LOS after lumbar fusion surgery with a high degree of accuracy.Data were obtained from the National Surgical Quality Improvement Program between 2009 and 2018. Demographic and comorbidity information was collected for patients who underwent anterior, anterolateral, or lateral transverse process technique arthrodesis procedure; anterior lumbar interbody fusion (ALIF); posterior, posterolateral, or lateral transverse process technique arthrodesis procedure; posterior lumbar interbody fusion/transforaminal lumbar interbody fusion (PLIF/TLIF); and posterior fusion procedure posterior spine fusion (PSF). Machine learning algorithmic analyses were done with the scikit-learn package in Python on a high-performance computing cluster. In the total sample, 85% of patients were used for training the models, whereas the remaining patients were used for testing the models. C-statistic area under the curve and prediction accuracy (PA) were calculated for each of the models to determine their accuracy in correctly classifying the test cases.In total, 12,915 ALIF patients, 27,212 PLIF/TLIF patients, and 23,406 PSF patients were included in the algorithmic analyses. The patient factors most strongly associated with LOS were sex, ethnicity, dialysis, and disseminated cancer. The machine learning algorithms yielded area under the curve values of between 0.673 and 0.752 (PA: 69.6% to 80.1%) for ALIF, 0.673 and 0.729 (PA: 66.0% to 81.3%) for PLIF/TLIF, and 0.698 and 0.749 (PA: 69.9% to 80.4%) for PSF.Machine learning classification algorithms were able to accurately predict long LOS for ALIF, PLIF/TLIF, and PSF patients. Supervised machine learning algorithms may be useful in clinical and administrative settings. These data may additionally help inform predictive analytic models and assist in setting patient expectations.Diagnostic study, retrospective cohort study.

Cauda equina syndrome is a potentially devastating spinal condition. The diagnosis of cauda equina syndrome lacks sensitivity and specificity, sometimes occurring after irreparable neurological damage has happened. Timely diagnosis and treatment is imperative for optimal outcomes and for avoiding medicolegal ramifications. Cauda equina syndrome results from conditions that compress the nerves in the lumbosacral spinal canal. Although no consensus definition exists, it generally presents with varying degrees of sensory loss, motor weakness, and bowel and bladder dysfunction (the latter of which is required to definitively establish the diagnosis). A thorough history and physical exam is imperative, followed by magnetic resonance or computed tomography imaging myelogram to aid in diagnosis and treatment. Once suspected, emergent spinal surgery referral is indicated, along with urgent decompression. Even with expeditious surgery, improvements remain inconsistent. However, early intervention has been shown to portend greater chance of neurologic recovery. All providers in clinical practice must understand the severity of this condition. Providers can optimize long-term patient outcomes and minimize the risk of litigation by open communication, good clinical practice, thorough documentation, and expeditious care.

Three-column osteotomy (3-CO) is a powerful tool for spinal deformity correction but has been associated with substantial risk and surgical invasiveness. It is incompletely understood how frailty might affect patients undergoing 3-CO.The PearlDiver database was used to examine spinal deformity patients with a diagnosis of frailty who had undergone 3-CO. Frail and nonfrail patients were matched, and the revision surgery rates, complications, and hospitalization costs were calculated. Logistic regression was used to account for possible confounding variables. Of the 2871 included patients, 1460 had had frailty and 1411 had had no frailty.The frail patients were older, had had more comorbidities (P0.001), and were more likely to have undergone posterior interbody fusion (P0.05), without differences in the anterior interbody fusion rates. No differences were found in the reoperation rates for ≤5 years. At 30 days, the frail patients were more likely to have experienced acute kidney injury (P = 0.018), bowel/bladder dysfunction (P = 0.014), cardiac complications (P = 0.006), and pneumonia (P = 0.039). At 2 years, the frail patients were also more likely to have experienced bowel/bladder dysfunction (P = 0.028), cardiac complications (P 0.001), deep vein thrombosis (P = 0.027), and sepsis (P = 0.033). The cost for the procedures was also higher for the frail patients than for the nonfrail patients ($24,544.79 vs. $21,565.63; P = 0.043).We found that frail patients undergoing 3-CO were more likely to experience certain medical complications and had had higher associated costs but similar reoperation rates compared with nonfrail patients. Careful patient selection and surgical strategy modification might alter the risks of medical and surgical complications after 3-CO for frail patients.

BACKGROUND Academic surgeons are invaluable for scientific advancement and training the next generation of orthopedic surgeons. OBJECTIVE This study aimed to describe a cohort of academic orthopedic surgeons currently in practice with common academic metrics. METHODS ACGME-accredited orthopedic surgery programs with a university affiliation were identified. The primary independent variable in this study was formal research training as defined by a research fellowship or attainment of a PhD. Outcomes included academic rank, h-index attained, number of publications, and funding by the National Institutes of Health (NIH). RESULTS 1641 orthopedic surgeons were identified across 73 programs. 116 surgeons (7.07%) received formal academic research training. The academic training group and non-academic training group had a similar completion rate of clinical fellowship programs (93.97% vs 93.77%, p=0.933), attainment of other advanced degrees (10.34% vs 8.46%, p=0.485), and years since completion of training (17.49-years vs 16.28-years, p=0.284). Surgeons completing academic research training had a significantly higher h-index (18.46 vs 10.88, p CONCLUSION Formalized research training, either as a research fellowship or PhD, is associated with an increased h-index and likelihood of NIH funding, although this association was not found for academic rank after adjusted regression analysis.

Fragility fractures, particularly in the hip and spine, are the most common complication of osteoporosis. In the US, approximately 1-1.5 million vertebral compression fractures (VCFs) occur annually. While patients may present with sudden onset of low back pain and limited mobility, more than two-thirds of VCFs are asymptomatic and are detected incidentally. X-rays are the standard imaging modality for diagnosis, with CT and MRI indicated if neurological deficits are present or a malignant cause is considered. Initial management is often non-surgical, with medications, physical therapy, and bracing. Surgical management in the form of cement augmentation (kyphoplasty or vertebroplasty) or instrumented fusion can be considered after failure of non-operative treatment, cases of deformity, or neurologic deficits. Subsequent VCFs occur frequently, and risk factors for refracture include advanced age, low bone mineral density, and low BMI. Treatment of primary VCFs with anti-resorptive medication is essential to reduce the risk of subsequent fractures.

Background Readmission after spine surgery is costly and a relatively common occurrence. Previous research identified several risk factors for readmission; however, the conclusions remain equivocal. Machine learning algorithms offer a unique perspective in analysis of risk factors for readmission and can help predict the likelihood of this occurrence. This study evaluated a neural network (NN), a supervised machine learning technique, to determine whether it could predict readmission after 3 lumbar fusion procedures. Methods The American College of Surgeons National Surgical Quality Improvement Program database was queried between 2009 and 2018. Patients who had undergone anterior, lateral, and/or posterior lumbar fusion were included in the study. The Python scikit Learn package was used to run the NN algorithm. A multivariate regression was performed to determine risk factors for readmission. Results There were 63,533 patients analyzed (12,915 anterior lumbar interbody fusion, 27,212 posterior lumbar interbody fusion, and 23,406 posterior spinal fusion cases). The NN algorithm was able to successfully predict 30-day readmission for 94.6% of anterior lumbar interbody fusion, 94.0% of posterior lumbar interbody fusion, and 92.6% of posterior spinal fusion cases with area under the curve values of 0.64–0.65. Multivariate regression indicated that age >65 years and American Society of Anesthesiologists class >II were linked to increased risk for readmission for all 3 procedures. Conclusions The accurate metrics presented indicate the capability for NN algorithms to predict readmission after lumbar arthrodesis. Moreover, the results of this study serve as a catalyst for further research into the utility of machine learning in spine surgery.

Background Back braces are commonly utilized in the management of low back pain (LBP). Objective The aim of this study is to evaluate (1) user satisfaction with a sacroiliac belt versus a lumbar orthosis and (2) the effect of a sacroiliac belt versus a lumbar orthosis on pain, functional disability status, and analgesic use for subjects with subacute or chronic non-specific LBP. Methods This is a prospective randomized crossover study. For the two-week study period, control group subjects wore the Horizon 627 Lumbar Brace (“lumbar orthosis”) during the first week and the Serola Sacroiliac Belt (“sacroiliac belt”) during the second week; experimental group subjects wore the sacroiliac belt during the first week and the lumbar orthosis during the second week. User satisfaction (Quebec User Evaluation of Satisfaction with Assistive Technology 2.0 [QUEST 2.0] score), functional disability status (Oswestry Disability Index [ODI]), pain, and analgesic use were recorded. Results Overall, the sacroiliac belt demonstrated significantly higher user satisfaction than the Horizon brace (QUEST Score = 20.31 vs. 16.17, p = 0.0375) for the entire study period. Significant negative correlations were identified between user satisfaction and functional disability (t = -4.71, p < 0.0001), pain magnitude (t = -6.81, p < 0.0001) as well as pain frequency (t = -6.66, p < 0.0001). Conclusion In this prospective randomized crossover study, subject satisfaction was associated with improvements in functional disability, pain magnitude and pain frequency. The sacroiliac belt demonstrated significantly higher user satisfaction and similar effectiveness compared to the lumbar orthosis.

Study Design Retrospective cohort study using PearlDiver database. Objectives To evaluate the effect of prior thyroidectomy on complications of Anterior Cervical Discectomy and Fusion (ACDF) surgery. Methods PearlDiver was used to identify patients without prior dysphagia or dysphonia undergoing ACDF between the years 2010-2020Q1. Patients with and without prior thyroidectomy were matched by levels of fusion, alcohol use, and gastroesophageal reflux disease in a 1:5 ratio. Postoperative outcomes were assessed for each cohort with multivariable logistic regression, controlling for age, sex, and Elixhauser Comorbidity Index. Results Between 2010 and 2019, matched cohorts of 792 ACDF patients with prior thyroidectomy and 3960 ACDF only patients were included in the study. Of patients with previous thyroidectomy undergoing ACDF, 16.3% experienced dysphagia at 1-year compared with 10.6% for patients undergoing ACDF only (aOR=1.39, P=.004). Patients with previous thyroidectomy also had higher odds of dysphonia at 1-year following ACDF, as compared to patients with ACDF alone (2.7% vs 1.2%, aOR=1.74, P= .048). Patients undergoing ACDF with prior thyroidectomy did not have increased risk of revision at 1 year (aOR=1.10, P=.698), 2 years (aOR=1.16, P=.457), or 5 years (aOR=1.20, P=.255) following surgery. There were no differences in postoperative opioid utilization rates at 1 month (aOR=2.07, P=.138), 3 months (aOR=2.45, P=.095), 6 months (aOR=1.34, P=.520), and 12 months (aOR=1.69, P=.202). Prior thyroidectomy was not associated with reintubation following ACDF (P=.995). Conclusions Patients with prior thyroidectomy undergoing ACDF surgery experience increased odds of dysphagia and dysphonia at 1-year follow-up compared to those without prior thyroidectomy.

The effect of spinopelvic fixation in addition to lumbar spinal fusion (LSF) on dislocation/instability and revision in patients undergoing primary total hip arthroplasty (THA) has not been reported previously.The PearlDiver Research Program was used to identify patients aged 30 and above undergoing primary THA who received (1) THA only, (2) THA with prior single-level LSF, (3) THA with prior 2-5 level LSF, or (4) THA with prior LSF with spinopelvic fixation. The incidence of THA revision and dislocation/instability was compared through logistic regression and Chi-squared analysis. All regressions were controlled for age, gender, and Elixhauser Comorbidity Index (ECI).Between 2010 and 2018, 465,558 patients without history of LSF undergoing THA were examined and compared to 180 THA patients with prior spinopelvic fixation, 5,299 with prior single-level LSF, and 1,465 with prior 2-5 level LSF. At 2 years, 7.8% of THA patients with prior spinopelvic fixation, 4.7% of THA patients with prior 2-5 level LSF, 4.2% of THA patients with prior single-level LSF, and 2.2% of THA patients undergoing only THA had a dislocation event or instability (P.0001). After controlling for length of fusion, pelvic fixation itself was associated with higher independent risk of revision (at 2 years: 2-5 level LSF + spinopelvic fixation: aHR = 3.15, 95% CI 1.77-5.61, P.0001 vs 2-5 level LSF with no spinopelvic fixation: aOR = 1.39, 95% CI 1.10-1.76, P.0001).At 2 years, spinopelvic fixation in THA patients were associated with a greater than 3.5-fold increase in hip dislocation risk compared to those without LSF, and an over 2-fold increase in THA revision risk compared to those with LSF without spinopelvic fixation.III.

Flexion-distraction, axial loading, and rotational forces can cause various degrees of osseoligamentous disruption of the cervical spine, leading to traumatic cervical facet fractures and dislocations.Low-energy forces lead to minimally displaced facet fractures that often can be treated with immobilization only. High-energy forces are more likely to cause unstable injuries with or without neurologic compromise, which may require surgical intervention.The initial treatment of cervical facet injuries requires patient evaluation and management through the Advanced Trauma Life Support (ATLS) protocols, while definitive management varies based on the biomechanical components of the injury, the neurologic status of the patient, and additional patient factors.Cervical facet injuries often require a multidisciplinary approach to optimize long-term functional outcomes and minimize serious complications.

Vertebral compression fractures are the most common fragility fractures affecting osteoporotic patients. This study evaluated volume trends and outcomes across specialties performing cement augmentation procedures.Patients were identified using Current Procedural Terminology codes for vertebroplasty or kyphoplasty from 2010 to 2019. Patients were grouped by surgical providers (orthopedic surgery and neurological surgery) or nonsurgical providers (anesthesia, pain medicine, radiology, and physical medicine and rehabilitation). Outcomes recorded included reoperation rates and postoperative complications occurring within 30 days. Logistic regression was employed to account for potential confounding variables, and odds ratios were obtained.Inclusion criteria were met by 80,864 patients who received cement augmentation. Surgeon specialists performed 51.7% of all procedures. Of procedures carried out by nonsurgeon specialists, radiologists performed the most. Despite a stable number of procedures performed over the period, the percentage of procedures performed by surgeons decreased from 58.8% to 49.9% (P0.001). Patients with procedures performed by surgeons experienced lower odds of reoperation at 30 days (P0.001) and 1 year (P0.001), but 5-year and overall rates were not significant (P0.05). Surgical patients had lower odds of acute kidney injury (P0.004) and pulmonary embolism (odds ratio = 0.62, P0.001), yet increased odds of surgical site infection (P0.001).Kyphoplasties and vertebroplasties are increasingly performed by nonsurgeon specialists. Although early reoperation rates are higher for nonsurgeon specialists, 5-year and overall reoperation rates were similar. Differing complication rates may relate to patient selection rather than operative technique and can be investigated with future studies.

Phantom limb syndrome is a debilitating complication after extremity amputation that poses significant challenges to recovery. This study aims to examine the relationship between phantom limb syndrome and mental and physical comorbidities, including a comparison between phantom limb pain and phantom limb syndrome without pain in below knee amputees.This is a retrospective cohort study of patients who underwent below knee amputation of the lower extremity in the PearlDiver database, as identified using CPT codes. Analysis was carried out to evaluate the absence or presence of phantom limb syndrome. Matched bivariate analysis accounting for age, sex, Charlson Comorbidity Index score, and region was used to assess whether the presence of pain in phantom limb syndrome patients was associated with increased comorbidity.In total, 44,028 patients with below knee amputation were examined: 95% (42,493 patients) did not develop phantom limb syndrome while 4.8% (1,535 patients) of patients did develop phantom limb syndrome. Phantom limb syndrome was significantly associated with increased odds of coexistent major depressive disorder (OR = 1.86, p0.0001), generalized anxiety disorder (OR = 2.14, p = 0.04), posttraumatic stress disorder (OR = 1.7, p0.0001), suicidal ideation (OR = 1.62, p0.0001), obesity (OR = 1.28, p = 0.0007), osteoarthritis (OR = 1.53, p0.0001), osteoporosis (OR = 1.64, p0.0001), and low back pain (OR = 2.31, p0.0001). Analysis of patient cohorts of phantom limb syndrome with pain and those without pain did not reveal a statistically significant relationship between the presence of pain and any dependent variable.This investigation of over 44,000 patients with below knee amputation revealed that patients with phantom limb syndrome exhibit significantly higher rate of psychiatric comorbidities compared to those without documented phantom limb pain. Suicidal ideation, major depressive disorder, generalized anxiety disorder, and post-traumatic stress disorder were especially common, and consequently a multi-disciplinary approach to management is essential.

Study Design Level III retrospective database study. Objectives The purpose of this study is to determine if machine learning algorithms are effective in predicting unplanned intubation following anterior cervical discectomy and fusion (ACDF). Methods The National Surgical Quality Initiative Program (NSQIP) was queried to select patients who had undergone ACDF. Machine learning analysis was conducted in Python and multivariate regression analysis was conducted in R. C-Statistics area under the curve (AUC) and prediction accuracy were used to measure the classifier’s effectiveness in distinguishing cases. Results In total, 54 502 patients met the study criteria. Of these patients, .51% underwent an unplanned re-intubation. Machine learning algorithms accurately classified between 72%-100% of the test cases with AUC values of between .52-.77. Multivariable regression indicated that the number of levels fused, male sex, COPD, American Society of Anesthesiologists (ASA) > 2, increased operating time, Age > 65, pre-operative weight loss, dialysis, and disseminated cancer were associated with increased risk of unplanned intubation. Conclusions The models presented here achieved high accuracy in predicting risk factors for re-intubation following ACDF surgery. Machine learning analysis may be useful in identifying patients who are at a higher risk of unplanned post-operative re-intubation and their treatment plans can be modified to prophylactically prevent respiratory compromise and consequently unplanned re-intubation.

The procedure of total hip arthroplasty (THA) is rapidly evolving. Patients undergoing THA are younger and more active, and they demand an earlier return to their daily activities. All of these factors increase both the early forces on uncemented femoral stems and the risk for complications. Consequently, surgeons must choose implants that provide immediate primary stability. This has led to renewed interest in the use of uncemented collared stems, which have benefits including increased primary stability, decreased risk of subsidence and periprosthetic fracture, and improved load transfer to the proximal femur. [ Orthopedics . 2022;45(3):e122–e126.]

Background Fragility hip fractures are a common orthopedic injury seen in Emergency Departments, with variable outcomes that can range from average to devastating. Currently, few reliable metrics to predict which patients will suffer post-operative complications exist. The aim of this study was to determine if the number and type of pre-operative medications can help predict post-operative complications. Methods A prospectively collected database of hip fracture patients was retrospectively reviewed. Patients with isolated greater trochanteric fractures, periprosthetic fractures, or re-fractures were excluded. Pre-operative baseline characteristics as well as number and type of post-operative complications were reviewed. Any complication within 6 months of surgery and complications that could be directly attributable to the surgical procedure within 2 years of surgery were examined. Major complications (return to the operating room, deep infection, pulmonary, cardiac, and hematologic) and minor medical complications were assessed. A multivariate regression model was performed to identify independent risk factors. Results Three-hundred ninety-one patients were included. A majority were aged 80–90 and female, and lived at home prior to presentation. Overall, 33.7% of patients suffered a complication within a 2-year follow-up period. Mortality rates were 5.4%, 10.0%, and 14.9% over 30 days, 1 year, and 2 years, respectively. After assessing this relationship while controlling for age, sex, injury type, pre-operative residence, ambulatory status, ASA score, and CCI score, the relationship remained significant for both an increased number of complications ( P = .048) and a higher likelihood of having a complication ( P = .008). Cardiovascular ( P = .003), pulmonary ( P = .001), gout ( P = .002), or diabetes ( P = .042) medications were associated with a higher likelihood for experiencing a complication. Conclusions Our study suggests that there is a strong and linear relationship between the number and type of pre-operative medications taken and risk of post-operative complications. This exists for up to 8 medications, at which point further increase does not contribute to an increased risk of complication. This relationship exists even after controlling for confounding variables and can be used by surgeons to better counsel patients and families regarding their specific risk for suffering perioperative complications.

Considerable interest has been expressed in the use of bisphosphonates to treat periprosthetic osteoporosis with the clinical goals of reducing periprosthetic fractures and prolonging implant survival.A systematic review was performed with the goal of identifying both basic science and clinical studies related to the risks and benefits of bisphosphonate use in total joint arthroplasty.Studies have shown that bisphosphonates may increase early bony ingrowth, decrease the postoperative loss of bone mineral density, and increase the longevity of implants by reducing the need for revisions secondary to aseptic loosening. Continuing bisphosphonates for 1 year postoperatively seems to provide the greatest benefit, with only marginal benefit being shown by continuing therapy for up to 2 years. Current data present some concerns for an increased risk of periprosthetic fractures especially in younger patients, and prolonged therapy is not recommended due to the potential risk of atypical femur fractures. Patients should be counseled regarding the risk of side effects of bisphosphonates, including the risk of osteonecrosis of the jaw, which is a rare but serious side effect. They should also be counseled on the risk of atypical femur fractures and gastrointestinal intolerance.Orthopedic surgeons could consider bisphosphonates for up to 1 year postoperatively regardless of the patient's prior bone mineral density, after discussion regarding the risks and benefits with the patient.

Normal pressure hydrocephalus (NPH) and degenerative cervical myelopathy (DCM) can each lead to gait dysfunction and urinary incontinence and may occur concurrently in some patients. In patients presenting with NPH and DCM, there is a paucity of literature describing the medical and surgical complications of treatment and the potential consequences of the sequence of surgical procedures. The aim of this study is to evaluate patients with DCM, NPH, and dual pathology to determine epidemiology and how the order of surgical intervention for both conditions may impact complications and patient outcomes.The PearlDiver Mariner database was queried between 2010 and 2020 to identify patients by their diagnosis of NPH, DCM, or both. Additional groups were created to identify cohorts of patients who underwent ventriculoperitoneal (VP) shunting, DCM surgery, or both surgeries, as determined by the CPT, ICD9, and ICD10 codes included in the dataset. Overall demographics were reported for these cohorts of patients including age, gender, and region. Multivariable logistic regression, controlling for age, sex, and Charlson Comorbidity Index, was used to calculate odds ratios for the rates of perioperative complications within 1 year of initial ventriculoperitoneal (VP) shunt and/or DCM surgery.A total of 825,989 patients were identified with DCM and/or NPH: 725,433 (87.8%) had myelopathy alone, 96, 411 (11.7%), had NPH alone, and 4145 patients (0.5%) had both NPH and DCM. Of all patients with NPH, 4.8% underwent DCM surgery. Of all patients with DCM, 0.08% underwent VP shunting. Compared to NPH only patients who underwent VP shunting, patients with both pathologies undergoing VP shunting had higher odds of revision at 1-year (OR: 1.33, p-value: 0.04) and 5-years (OR: 1.36, p-value: 0.011), as well as spinal cord injury (OR: 7.77, p-value 0.016), dysphonia (OR: 2.88, p-value: 0.004), cervicalgia (OR: 2.95, p-value: 0.004), cervical kyphosis (OR: 17.49, p-value: 0.004), and limb paralysis (OR: 2.02, p-value: 0.002). Compared to DCM only patients who underwent DCM surgery, patients with both pathologies undergoing DCM surgery had higher odds of cardiac complications (OR: 1.12, p-value: 0.002), dural tear (OR: 1.66, p-value: 0.029), and dysphagia (OR: 1.28, p-value:0.001). Patients who underwent VP shunting prior to DCM surgery had higher odds of revision shunting surgery at 1-year (OR:1.61, p-value:0.03) and 5- years (OR:2.16, p-value:0.001).This is the largest study to date examining patients with dual cervical myelopathy and normal pressure hydrocephalus. Surgeons should carefully consider the order of VP shunting and DCM surgery, as complication rates differ depending on the order in which these surgeries are performed. Shunt revision is more common when VP shunting is performed prior to spinal decompression.

Antibiotic bone cement (ABC) is an effective tool for the prophylaxis and treatment of osteomyelitis due to the controlled, sustained release of local antibiotics. ABC has been proven to be effective in the orthopedic fields of arthroplasty and extremity trauma, but the adoption of ABC in spine surgery is limited. The characteristics of ABC make it an optimal solution for treating vertebral osteomyelitis (VO), a serious complication following spine surgery, typically caused by bacterial and sometimes fungal and parasitic pathogens. VO can be devastating, as infection can result in pathogenic biofilms on instrumentation that is dangerous to remove. New techniques, such as kyphoplasty and novel vertebroplasty methods, could amplify the potential of ABC in spine surgery. However, caution should be exercised when using ABC as there is some evidence of toxicity to patients and surgeons, antibiotic allergies, bone cement structural impairment, and possible development of antibiotic resistance. The purpose of this article is to describe the basic science of antibiotic cement utilization and review its usage in spine surgery.

» The United States has faced substantial increases in health-care expenditure, with specifically large increases in spine surgery costs. » Many different formulas are utilized to determine value in spine surgery, including cost- benefit analyses, cost-effectiveness analyses, and cost-utility analyses, with the overall determination of value being quality/cost. » Quality often is calculated indirectly using either process measures or outcome measures and represents the potential benefit of a given intervention, usually over a specific time period to yield quality-adjusted life years. » Costs are particularly difficult to calculate given the interhospital, regional, national, and global variability, as well as indirect costs of an intervention, and many different methods are utilized to estimate costs. » Spine surgeons should be familiar with the elements that compose cost-effectiveness and their potential shortcomings in order for providers and health-care policy makers to identify the highest-quality studies and interventions that provide the greatest benefit to patients.

Mortality following surgical resection of spinal tumors is a devastating outcome. Naïve Bayes machine learning algorithms may be leveraged in surgical planning to predict mortality. In this investigation, we use a Naïve Bayes classification algorithm to predict mortality following spinal tumor excision within 30 days of surgery.Patients who underwent laminectomies between 2006 and 2018 for excisions of intraspinal neoplasms were selected from the National Surgical Quality Initiative Program. Naïve Bayes classifier analysis was conducted in Python. The area under the receiver operating curve (AUC) was calculated to evaluate the classifier's ability to predict mortality within 30 days of surgery. Multivariable logistic regression analysis was performed in R to identify risk factors for 30-day postoperative mortality.In total, 2094 spine tumor surgery patients were included in the study. The 30-day mortality rate was 5.16%. The classifier yielded an AUC of 0.898, which exceeds the predictive capacity of the National Surgical Quality Initiative Program mortality probability calculator's AUC of 0.722 (P0.0001). The multivariable regression indicated that smoking history, chronic obstructive pulmonary disease, disseminated cancer, bleeding disorder history, dyspnea, and low albumin levels were strongly associated with 30-day mortality.The Naïve Bayes classifier may be used to predict 30-day mortality for patients undergoing spine tumor excisions, with an increasing degree of accuracy as the model better performs by learning continuously from the input patient data. Patient outcomes can be improved by identifying high-risk populations early using the algorithm and applying that data to inform preoperative decision making, as well as patient selection and education.

Background Spinal cord stimulation (SCS) has become a successful therapeutic option for combating chronic pain and can be implanted via percutaneous or open (laminotomy/laminectomy) techniques. This study aimed to systematically review the complications that occur after SCS placement via percutaneous and open (laminotomy/laminectomy) in failed back surgery syndrome (FBSS), complex regional pain syndrome (CRPS), and chronic back (lumbosacral)/leg pain. Methods The PubMed and Embase databases were searched from inception to June 2020; prospective studies using SCS in patients with FBSS, CRPS, and chronic low back pain that reported both complications and the implantation method used were included. Effects and results from each study were combined using a random-effects model and were structured for subgroup analysis between open implantation and percutaneous implantation. Meta-regression was performed by calculating a mean difference and weighted by inverse variance and 95% confidence intervals (CIs). Results Thirty-two articles were included in this systematic review and meta-analysis. Using several different patient- and event-based metrics, our meta-analysis revealed an overall average complication rate of 21.1% (95% CI, 14.9–27.2). Equipment, technical, and medical complications occurred at rates of 12.1%, 1.1%, and 6.3%, respectively. Lead migration and infection rates were 5.6% and 3.8%, respectively. When comparing the 2 implant techniques, medical-related surgical reinterventions and explants due to infection were more common in open compared with percutaneous SCS procedures. Conclusions Equipment-related complications accounted for the majority of SCS complications. Percutaneous SCS resulted in less reintervention and fewer explants caused by medical-related complications and infection, respectively. These conclusions may provide a general understanding of the SCS complications profile for physicians who care for SCS patients.

Sudden cardiac death in young athletes is a devastating condition that occurs without warning. While most middle and high school athletes require preparticipation screening, many predisposing conditions go undiagnosed until they occur. The frequency of sudden cardiac death is often under-reported because there is no mandatory system for reporting sports-related death in high school sports. Additionally, there is debate about the cost-effectiveness of more advanced screening tests, such as electrocardiogram, due to high false-positive rates. It is, however, accepted that participants with a family history of sudden cardiac death should undergo more in-depth screening. If sudden cardiac arrest occurs, it is important for the patient to undergo immediate defibrillation. Community outreach to ensure that automated external defibrillators are present at athletic events, as well as cardiopulmonary resuscitation training for coaches, could potentially save lives. Ultimately, prevention of sudden cardiac death depends on physician awareness of how to properly screen and identify those at risk, and how to best be prepared if sudden cardiac arrest occurs.

The SCN1A gene has been implicated in the etiology of various forms of epilepsy. New research has linked this gene to specific types of epilepsy, all of which present in infancy or early childhood. This study examines the time course and pathology of pediatric patients who have a mutation in the SCN1A gene in order to open a discussion regarding the key trends of this form of epilepsy as well as important clinical considerations in management for patients who present with symptoms relating to the SCN1A mutations. We retrospectively examined 20 patients who presented to the clinic with focal seizures, as well as were positive for an SCN1A genetic mutation. Despite the small sample size, we were able to find important trends in the time course of the disorder as well as important areas of clinical practice that must be taken into consideration for these patients.

Adult spinal deformity (ASD) is a challenging problem for spine surgeons given the high risk of complications, both medical and surgical. Surgeons should have a high index of suspicion for medical complications, including cardiac, pulmonary, thromboembolic, genitourinary and gastrointestinal, renal, cognitive and psychiatric, and skin conditions, in the perioperative period and have a low threshold for involving specialists. Surgical complications, including neurologic injuries, vascular injuries, proximal junctional kyphosis, durotomy, and pseudarthrosis and rod fracture, can be devastating for the patient and costly to the health-care system. Mortality rates have been reported to be between 1.0% and 3.5% following ASD surgery. With the increasing rate of ASD surgery, surgeons should properly counsel patients about these risks and have a high index of suspicion for complications in the perioperative period.

The SCN1A gene has been implicated in the etiology of various forms of epilepsy. New research has linked this gene to specific types of epilepsy, all of which present in infancy or early childhood. This study examines the time course and pathology of pediatric patients who have a mutation in the SCN1A gene in order to open a discussion regarding the key trends of this form of epilepsy as well as important clinical considerations in management for patients who present with symptoms relating to the SCN1A mutations. We retrospectively examined 20 patients who presented to the clinic with focal seizures, as well as were positive for an SCN1A genetic mutation. Despite the small sample size, we were able to find important trends in the time course of the disorder as well as important areas of clinical practice that must be taken into consideration for these patients.