Search

Objective: /Background: Venous thromboembolism (VTE) is a serious postoperative adverse event after spine surgery. In patients with pain refractory to typical multimodal analgesia regimens after spine surgery, whom are often chronic opioid users, perioperative ketamine is an alternative analgesic that has grown in popularity. The aim of this study is to assess the risk of venous thromboembolism (VTE) in chronic opioid users undergoing spine surgery., Methods: We conducted a structured query language (SQL) search to identify patients with a diagnosis of VTE after spine surgery from 2017-2021. SQL identified patient demographic information and chart review was performed to confirm procedure details, including levels fused and decompressed. Opioid use was identified using the Prescription Drug Monitoring Program (PDMP) for each patient. Chronic opioid users were defined as having >180 days or >9 opioid prescriptions prescribed in the 12 months prior to surgery., Results: 322 total patients were identified with complete PDMP and postoperative ketamine data, including 29 patients with confirmed VTE after spine surgery. Length of stay (p<0.001) and Elixhauser comorbidity index (p=0.008) were significantly greater in the VTE group compared to the no VTE group. Analysis of only chronic opioid users also found a significant association between postoperative ketamine and VTE (p=0.034)., Conclusions: Our study found no association between chronic opioid use and VTE occurrence; however, we identified a significant association between ketamine infusion and VTE after spine surgery. Further studies should be conducted to identify the risks associated with ketamine and other newly implemented alternative analgesics., (Copyright © 2024. Published by Elsevier Inc.)

Background Context: There is significant variability in postoperative chemoprophylaxis protocols amongst spine providers due to perceived risks and benefits, but limited data on the topic. At our institution, both orthopaedic spine and neurosurgery departments utilize unfractionated subcutaneous heparin in identical dosages and frequency, with the only difference being time to initiation postoperatively., Purpose: To evaluate the rate of symptomatic venous thromboembolism (VTEs) and unplanned reoperation for hematoma based on timing of chemoprophylaxis initiation., Study Design/setting: Single institution retrospective cohort study., Patient Sample: Patients undergoing elective spine surgery, excluding patients undergoing surgery in the setting of trauma, malignancy, or infection., Outcome Measures: Outcome measures included the diagnosis of a venous thromboembolism within 90 days of surgery and unplanned reoperation for a hematoma., Methods: Patients undergoing elective spine surgery from 2017 to 2021 were grouped based on chemoprophylaxis protocol. In the "immediate" group, patients received subcutaneous heparin 5000 units every 8 hours starting immediately after surgery, and in the "delayed" group, patients received chemoprophylaxis starting postoperative day (POD)-2 for any decompressions and/or fusions involving a spinal cord level (ie, L2 and above) and POD-1 for those involving only levels below the spinal cord (ie, L3 to pelvis). A cox proportional hazards model was created to assess independent predictors of venous thromboembolic events, while a logistic regression was utilized for unplanned reoperations for hematoma., Results: Of 8,704 patients, a total of 98 (1.13%) VTE events occurred, of which 43 (0.49%) were pulmonary embolism. Fifty-four patients (0.62%) had unplanned reoperations for postoperative hematomas. On cox proportional hazards model analysis, immediate chemoprophylaxis was not protective of a venous thromboembolism (Hazard Ratio: 1.18, p=.436), but, it was a significant independent predictor for unplanned reoperation for hematoma on multivariable logistic regression modeling (Odds Ratio: 3.29, p<.001)., Conclusions: Both chemoprophylaxis protocols in our study resulted in low rates of VTE and postoperative hematoma. However, our findings suggest that the delayed chemoprophylaxis protocol may mitigate postoperative hematoma formation without increasing the risk for a thrombotic event., Competing Interests: Declaration of competing interest One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Study Design: Retrospective cohort study., Objective: The objective of this study was to investigate associations between spine surgeon characteristics and different types of industry payments., Summary of Background Data: Industry funding has played an important role in research and technological innovation within spine surgery, and industry payments supporting research have risen significantly in comparison to funding from other sources. To our knowledge, no studies have investigated academic spine surgeon characteristics associated with different categories of industry payments., Materials and Methods: A query was conducted of the North American Spine Society Spine Fellowship Directory from 2021 to 2022 to identify all orthopaedic or neurosurgical spine fellowship selection committee members. A PubMed search was utilized to collect information on surgeon academic productivity up through December 31, 2021. The authors then conducted a query on the Centers for Medicare and Medicaid Services open payments website from 2015 to 2021 to collect payment records of spine fellowship selection committee members., Results: On linear regression analysis, total publications (8203, P <0.001), attending years (48,823, P <0.001), and publication rate (57,528, P =0.017) were associated with higher general payments. Southeast spine surgeons (80,043, P =0.038) and fellowship directors (79,874, P =0.007) were associated with more research payments. Total publications (7409, P <0.001), attending years (47,100, P <0.001), and publication rate (47,511, P =0.040) were significantly associated with higher royalties. Having a Twitter/X account (60,800, P =0.018), being a director (51,605, P =0.034), total publications (492, P <0.001), and publication rate (6444, P <0.001) were all predictive of greater consulting payments., Conclusions: Spine surgeons who are experienced, academically productive, fellowship directors, and engage with social media receive greater payments on average than their peers across various payment types. As industry influence continues to make its way into health care, experienced leaders in their respective fields will shoulder the responsibility to integrate private innovation in an effective and scientifically rigorous manner., Level of Evidence: 3., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Revision lumbar fusion is most commonly due to nonunion, adjacent segment disease (ASD), or recurrent stenosis, but it is unclear if diagnosis affects patient outcomes. The primary aim of this study was to assess whether patients achieved the patient acceptable symptom state (PASS) or minimal clinically important difference (MCID) after revision lumbar fusion and assess whether this was influenced by the indication for revision., Methods: We retrospectively identified all 1-3 level revision lumbar fusions at a single institution. Oswestry Disability Index (ODI) was collected at preoperative, three-month postoperative, and one-year postoperative time points. The MCID was calculated using a distribution-based method at each postoperative time point. PASS was set at the threshold of ≤ 22., Results: We identified 197 patients: 56% with ASD, 28% with recurrent stenosis, and 15% with pseudarthrosis. The MCID for ODI was 10.05 and 10.23 at three months and one year, respectively. In total, 61% of patients with ASD, 52% of patients with nonunion, and 65% of patients with recurrent stenosis achieved our cohort-specific MCID at one year postoperatively with ASD (p = 0.78). At one year postoperatively, 33.8% of ASD patients, 47.8% of nonunion patients, and 37% of patients with recurrent stenosis achieved PASS without any difference between indication (p = 0.47)., Conclusions: The majority of patients undergoing revision spine fusion experience significant postoperative improvements regardless of the indication for revision. However, a large proportion of these patients do not achieve the patient acceptable symptom state. While revision spine surgery may offer substantial benefits, these results underscore the need to manage patient expectations., (© 2024. The Author(s).)

Objective: The Pfirrmann scoring system classifies lumbosacral disc degeneration based on magnetic resonance imaging signal intensity. The relationship between pre-existing disc degeneration and patient-reported outcome measures (PROMs) after one-level lumbar fusion is not well documented. The purpose of this study was to investigate the relationship between the severity of preoperative intervertebral disc degeneration and preoperative and postoperative PROMs in patients undergoing one-level lumbar fusion., Methods: All adult patients who underwent posterior lumbar decompression and fusion or transforaminal lumbar interbody fusion between 2014 and 2022 were included. Patient demographics and comorbidities were extracted from medical records. Lumbar intervertebral discs on sagittal magnetic resonance imaging T2-weighted images were assessed by 2 independent graders utilizing Pfirrmann criteria. Grades I-III were categorized as low-grade disc degeneration, while IV-V were considered high grade. Multivariable linear regression assessed the impact of disc degeneration on PROMs., Results: A total of 150 patients were included, of which 69 (46%) had low-grade disc degeneration, while 81 (54%) had high-grade degeneration. Patients with high-grade degeneration had increased preoperative visual analog scale (VAS)-Leg scores (6.10 vs. 4.54, P = 0.005) and displayed greater 1-year postoperative improvements in VAS-Back scores (-2.11 vs. -0.66, P = 0.002). Multivariable regression demonstrated Pfirrmann scores as independent predictors for both preoperative VAS-Leg scores (P = 0.004) and postoperative VAS-Back improvement (P = 0.005)., Conclusions: In patients undergoing one-level lumbar fusion, higher Pfirmann scores were associated with increased preoperative leg pain and greater 1-year postoperative improvement in back pain. Further studies into the relationship of preoperative disc degeneration and their impact on postoperative outcomes may help guide clinical decision-making and patient expectations., (Copyright © 2024. Published by Elsevier Inc.)

Purpose: To report the rate of fusion in a sample of patients undergoing lumbar fusion surgery and assess interrater reliability of computed tomography (CT)-based parameters for the assessment of fusion., Methods: All adult patients who underwent lumbar fusion surgery from 2017 to 2021 were retrospectively identified. Patient demographics and surgical characteristics were collected through chart review of the electronic medical records. CT scans were reviewed independently by two attending spine surgeons and two spine fellows. Fusion was defined as evidence of bone bridging in any one of (1) posterolateral gutters, (2) facets, or (3) interbody (when applicable) on any CT views. Evidence of screw haloing was indicative of nonunion. Interrater reliability was determined using cohen's kappa. Afterwards, a consensus agreement for each component of fusion was reached between participants., Results: The overall fusion rate among all procedures was 63/69 (91.3%). Overall 22/25 (88.0%) TLIF, 16/19 (84.2%) PLDF, 3/3 (100%) LLIF, and 22/22 (100%) circumferential fusions experienced a successful fusion. Interrater reliability was good for interbody fusion (k = 0.734) and moderate for all other measures (k = 0.561 for posterolateral fusion; k = 0.471 for facet fusion; k = 0.458 for screw haloing). Overall, interrater reliability as to whether a patient had a fusion or nonunion was moderate (k = 0.510)., Conclusion: There was only moderate interrater reliability across most radiographic measures used in assessing lumbar fusion status. Reliability was highest when evaluating the presence of interbody fusion. The majority of fusions occurred across the facet joints., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Study Design: Systematic Review and meta-analysis., Objective: To conduct an updated systematic review and meta-analysis of complications associated with different anterior fusion techniques/approaches and adjuvant resources (i.e., computed tomography angiography (CTA), rhBMP-2, and access surgeons)., Methods: A systematic review was conducted from 1/1/2014-4/1/2024 for studies evaluating the incidence of complications associated with anterior lumbar procedures. Comparisons of complications were made between surgical approach, use of CTA, rhBMP-2, and access surgeons. Meta-analyses were conducted using a generalized linear mixed model., Results: 54 studies were included in the final analysis with 8066 patients and an average follow-up of 31.2 months. The overall complication rate associated with anterior lumbar surgery was 13.1%, including an intraoperative complication rate of 3.8%, postoperative complication rate of 7.4%, infection rate of 1.5%, and reoperation rate of 1.7%. Forest plot analysis showed no significant difference in overall complication rates between open and mini-open techniques, although mini-open techniques were associated with lower overall reoperation rates. The use of CTA was associated with an increase in intraoperative and overall complications, and the use of an access surgeon was associated with a decreased risk of reoperation. The use of rhBMP-2 was not associated with overall complication risk., Conclusions: While anterior lumbar surgery provides numerous benefits, surgeons and patients alike should be aware of the complication and safety profile prior to surgery. High quality studies are warranted to help elucidate the true benefit of certain techniques and adjuvant resources in reducing complications., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Study Design: Retrospective cohort study., Objective: To compare outcomes in anteriorly placed transforaminal lumbar interbody fusions (TLIFs) and anterior lumbar interbody fusions (ALIFs)., Summary of Background Data: TLIF and ALIF are surgical techniques that have become more prevalent in recent years. Although studies have compared the two, none have considered TLIFs with anteriorly placed cages, which may serve as a better comparison to ALIFs., Patients and Methods: Patients undergoing TLIF or ALIF with posterior instrumentation from 2010 to 2020 at a tertiary care institution were retrospectively identified. TLIF cage position was assessed and those with anterior placement were included. Electronic medical records were reviewed to identify patient characteristics and patient-reported outcomes. Radiographic outcomes included posterior disc height (DH), lumbar lordosis (LL), sacral slope, pelvic incidence, and pelvic tilt. Statistical analysis was performed to compare the two groups., Results: Of the 351 patients, 108 had ALIF with posterior instrumentation and 207 had a TLIF. Preoperatively, patients undergoing TLIF had less LL (53.7° vs . 60.6°, P < 0.001), sacral slope (38.3° vs . 43.7°, P < 0.001), and pelvic incidence (60.1° vs . 66.1°, P < 0.001), all of which remained significant at 1-year and long-term follow-up ( P < 0.001). The TLIF group had less ∆DH (1.51° vs . 5.43°, P < 0.001), ∆LL (1.8° vs . 2.97°, P = 0.038), and ∆segmental lordosis (0.18° vs . 4.40°, P < 0.001) at 1 year postoperatively. At 2 to 3 years, ∆DH ( P < 0.001) and ∆segmental lordosis ( P = 0.001) remained significant, but ∆LL ( P = 0.695) did not. Patients in the TLIF group had higher Visual Analog Scale-Back scores 1 year postoperatively (3.68 vs . 2.16, P = 0.008) and experienced less improvement in Oswestry Disability Index (-17.1 vs . -28.6, P = 0.012) and Visual Analog Scale-Back (-2.67 vs . -4.50, P = 0.008) compared with patients undergoing ALIF., Conclusions: Our findings suggest that ALIF with posterior instrumentation performed superiorly in radiographic outcomes and patient-reported outcomes compared with anteriorly placed TLIFs. Anteriorly placed TLIF cages may not achieve the same results as those of ALIF cages., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective cohort study., Objective: To evaluate how preoperative Oswestry Disability Index (ODI) thresholds might affect minimal clinically important difference (MCID) achievement following lumbar fusion., Summary of Background Data: As payers invest in alternative payment models, some are suggesting threshold cutoffs of patient-reported outcomes (PROMs) in reimbursement approvals for orthopedic procedures. The feasibility of this has not been investigated in spine surgery., Materials/methods: We included all adult patients undergoing one to three-level primary lumbar fusion at a single urban tertiary academic center from 2014 to 2020. ODI was collected preoperatively and one year postoperatively. We implemented theoretical threshold cutoffs at increments of 10. MCID was set at 14.3. The percent of patients meeting MCID were determined among patients "approved" or "denied" at each threshold. At each threshold, the positive predictive value (PPV) for MCID attainment was calculated., Results: A total 1368 patients were included and 62.4% (N=364) achieved MCID. As the ODI thresholds increased, a greater percent of patients in each group reached the MCID. At the lowest ODI threshold, 6.58% (N=90) of patients would be denied, rising to 20.2%, 39.5%, 58.4%, 79.9%, and 91.4% at ODI thresholds of 30, 40, 50, 60, and 70, respectively. The PPV increased from 0.072 among patients with ODI>20 to 0.919 at ODI>70. The number of patients denied a clinical improvement in the denied category per patient achieving the MCID increased at each threshold (ODI>20: 1.96; ODI>30: 2.40; ODI>40: 2.75; ODI>50: 3.03; ODI>60: 3.54; ODI>70: 3.75)., Conclusion: Patients with poorer preoperative ODI are significantly more likely to achieve MCID following lumbar spine fusion at all ODI thresholds. Setting a preoperative ODI threshold for surgical eligibility will restrict access to patients who may benefit from spine fusion despite ODI>20 demonstrating the lowest predictive value for MCID achievement., Level of Evidence: 3., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Prospective multicenter cohort study., Objective: To explore the association between operative level and postoperative dysphagia after anterior cervical discectomy and fusion (ACDF)., Background: Dysphagia is common after ACDF and has several risk factors, including soft tissue edema. The degree of prevertebral soft tissue edema varies based on the operative cervical level. However, the operative level has not been evaluated as a source of postoperative dysphagia., Patients and Methods: Adult patients undergoing elective ACDF were prospectively enrolled at 3 academic centers. Dysphagia was assessed using the Bazaz Questionnaire, Dysphagia Short Questionnaire, and Eating Assessment Tool-10 (EAT-10) preoperatively and at 2, 6, 12, and 24 weeks postoperatively. Patients were grouped based on the inclusion of specific surgical levels in the fusion construct. Multivariable regression analyses were performed to evaluate the independent effects of the number of surgical levels and the inclusion of each particular level on dysphagia symptoms., Results: A total of 130 patients were included. Overall, 24 (18.5%) patients had persistent postoperative dysphagia at 24 weeks and these patients were older, female, and less likely to drink alcohol. There was no difference in operative duration or dexamethasone administration. Patients with persistent dysphagia were significantly more likely to have C4-C5 included in the fusion construct (62.5% vs . 34.9%, P = 0.024) but there were no differences based on the inclusion of other levels. On multivariable regression, the inclusion of C3-C4 or C6-C7 was associated with more severe EAT-10 (β: 9.56, P = 0.016 and β: 8.15, P = 0.040) and Dysphagia Short Questionnaire (β: 4.44, P = 0.023 and (β: 4.27, P = 0.030) at 6 weeks. At 12 weeks, C3-C4 fusion was also independently associated with more severe dysphagia (EAT-10 β: 4.74, P = 0.024)., Conclusion: The location of prevertebral soft tissue swelling may impact the duration and severity of patient-reported dysphagia outcomes at up to 24 weeks postoperatively. In particular, the inclusion of C3-C4 and C4-C5 into the fusion may be associated with dysphagia severity., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Intraosseous basivertebral nerve ablation is indicated for the treatment of chronic vertebrogenic low back pain with failure of at least 6 months of conservative treatment. This article details patient positioning and setup, step-by-step instructions for the procedure, and postoperative management. Pearls and pitfalls are also discussed. In addition, an instructional procedure video accompanies this paper and can be found online (at https://vimeo.com/791578426/de0e90cfbe)., Competing Interests: Dr Schroeder has received funds to travel from AOSpine and Medtronic. The remaining authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Observational study., Objective: To evaluate the readability of commonly utilized patient-reported outcome measures (PROMs) in spine surgery., Summary of Background Data: Although studies have evaluated patient education materials, discharge instructions, and informed consent forms in spine surgery, there is a dearth of literature on the readability of PROMs despite widespread health illiteracy. Without knowledge of PROM readability, it is unclear whether these measures are able to be understood by the average spine patient., Materials and Methods: We analyzed all commonly utilized nonvisual PROMs within the spinal literature and uploaded PROMs into an online readability calculator. The Flesch Reading Ease Score (FRES) and Simple Measure of Gobbledygook (SMOG) Index were collected. A FRES>79 or SMOG<7 was considered readable by the general population per American Medical Association and Centers for Disease Control guidelines. A stricter threshold recommended in health care (SMOG <6 or FRES>89) was then used to further review readability., Results: Seventy-seven PROMs were included. Based on FRES, the mean readability of all PROMs was 69.2 ± 17.2 (range, 10-96.4), indicating an average eighth to ninth-grade reading level. The mean readability score categorized by the SMOG Index was 8.12 ± 2.65 (range, 3.1-25.6), representing an eighth-grade reading level. Compared with the reading level of the general population, 49 (63.6%) PROMs are written above the United States literacy level, according to FRES. Using stricter definitions of readability, 8 PROMs were considered readable, including PROM Information System pain behavior (FRES: 96.4 and SMOG: 5.2), PROM Information System sleep disturbance (SMOG: 5.6), Neck Pain and Disability Scale (SMOG: 4.3), and Zung Depression Scale (SMOG: 3.1)., Conclusions: Most PROMs utilized in spine surgery require an average reading competency far above the average patient's comprehension. This may have a meaningful impact on understanding PROM instruments and may affect the accuracy of complete surveys and the rates of incompletion., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Substantial data support a heritable basis for supraventricular tachycardias, but the genetic determinants and molecular mechanisms of these arrhythmias are poorly understood. We sought to identify genetic loci associated with atrioventricular nodal reentrant tachycardia (AVNRT) and atrioventricular accessory pathways or atrioventricular reciprocating tachycardia (AVAPs/AVRT)., Methods: We performed multiancestry meta-analyses of genome-wide association studies to identify genetic loci for AVNRT (4 studies) and AVAP/AVRT (7 studies). We assessed evidence supporting the potential causal effects of candidate genes by analyzing relations between associated variants and cardiac gene expression, performing transcriptome-wide analyses, and examining prior genome-wide association studies., Results: Analyses comprised 2384 AVNRT cases and 106 489 referents, and 2811 AVAP/AVRT cases and 1,483 093 referents. We identified 2 significant loci for AVNRT, which implicate NKX2-5 and TTN as disease susceptibility genes. A transcriptome-wide association analysis supported an association between reduced predicted cardiac expression of NKX2-5 and AVNRT. We identified 3 significant loci for AVAP/AVRT, which implicate SCN5A , SCN10A , and TTN/CCDC141 . Variant associations at several loci have been previously reported for cardiac phenotypes, including atrial fibrillation, stroke, Brugada syndrome, and electrocardiographic intervals., Conclusions: Our findings highlight gene regions associated with ion channel function (AVAP/AVRT), as well as cardiac development and the sarcomere (AVAP/AVRT and AVNRT) as important potential effectors of supraventricular tachycardia susceptibility., Competing Interests: Disclosures Dr Lubitz is a full-time employee of Novartis as of July 2022. Previously, Dr Lubitz received research support from Bristol Myers Squibb/Pfizer, Bayer AG, Boehringer Ingelheim, Fitbit, IBM, Medtronic, and Premier, Inc, and consulted for Bristol Myers Squibb/Pfizer, Bayer AG, Blackstone Life Sciences, and Invitae. Dr Ellinor receives research support from Bayer AG, IBM, and Bristol Myers Squibb/Pfizer and has consulted for Novartis, MyoKardia, and Bayer AG. Dr Damrauer receives research support for RenalytixAI and has consulted for Calico Labs. Dr Svendsen is a member of Medtronic advisory boards and has received speaker honoraria and research grants from Medtronic outside this work. Dr Cutler has consulted for Janssen Scientific. Dr Roselli is supported by a grant from Bayer AG to the Broad Institute focused on the development of therapeutics for cardiovascular disease. The other authors report no conflicts.

Background: This study examined the effect of prior pulmonary embolism (PE) on total joint arthroplasty (TJA) outcomes., Methods: We reviewed patients who had a prior PE undergoing TJA at a single tertiary medical center between January 1, 2012 and January 1, 2021. There were 177 TJA patients who had a prior PE who underwent 1:3 propensity-matching to patients without a history of prior PE. Bivariable and multivariable analyses were performed. Changes over time were evaluated., Results: Patients undergoing total knee arthroplasty who had a prior PE had more complications (25.3% versus 2.0%, P < .001), and postoperative PE (17.3% versus 0.0%, P < .001).and longer hospitalizations (3.15 versus 2.32 days, P = .006). Patients undergoing total hip arthroplasty who had a prior PE demonstrated more complications (14.7% versus 1.77%, P < .001) more postoperative PE (17.3% versus 0.0%, P < .001), and longer hospitalizations (3.30 versus 2.11 days, P < .001). Over the study, complication rates and hospitalizations lengths remained elevated in patients who had a prior PE. On multivariate analyses, prior PE was associated with longer hospitalizations (β: 0.67, P = .015) and increased complications (odds ratio [OR]: 9.44, P < .001) among total hip arthroplasty patients. Total knee arthroplasty patients had increased readmission (OR: 4.89, P = .003) and complication rates (OR: 21.4, P < .001)., Conclusions: Patients undergoing TJA who had a prior PE are at higher risk of requiring postoperative care. Therefore, thorough preoperative evaluation must be implemented, especially in clinical environments lacking resources for acute care escalation., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The operative treatment for thoracic outlet syndrome (TOS) varies in the United States. This may be due to differences in specialty training of the provider. We sought to identify which procedures are primarily performed by specialty, identify patient characteristics presenting for different neurogenic TOS surgical interventions, and describe the safety of TOS surgery., Methods: Patients treated for neurogenic TOS between 2016 and 2018 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Patient characteristics, surgeon details, intraoperative variables, and complication outcomes were abstracted. Patient cohorts were stratified by type of operative intervention and by treating specialty., Results: Transthoracic first rib resection was the most common procedure performed for TOS relief (46.1%), followed by division of the scalene muscles with rib resection (23.9%) and brachial plexus exploration with decompression (19.4%). Vascular surgeons performed 87% of TOS repairs. Thirty-day complication rate was 3.5%. Addition of scalenectomy to first rib resection was common and resulted in increased operative time but did not increase early complication rate or readmission rate., Conclusion: Patient characteristics and dispositions are similar between the various TOS operative approaches. All major surgical treatments for TOS have low complication rates. Transthoracic first rib resection performed by vascular surgeons remains the most common surgical treatment for patients with TOS in the United States. Despite neurogenic symptoms representing most cases, less than 10% of operations are performed by peripheral nerve specialists, highlighting a potential need for greater incorporation of TOS release into peripheral nerve practices., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Patients presenting with spinal cord injury (SCI) often times have notable deficits or polytrauma and may require urgent decision making for early management. However, their presentation may affect decision-making ability. Although advance care planning (ACP) may help guide spine surgeons as to patient preferences, the rate at which they are available and disparities in ACP completion are still not understood. The objective of this study was to evaluate disparities in the completion of ACP among patients with acute SCI., Methods: All patients presenting with cervical SCI to the emergency department at an urban, tertiary level I trauma center from 2010 to 2021 were identified from a prospective database of all consults evaluated by the spine service. Each patient's medical record was reviewed to assess for the presence of ACP documents such as living will, power of attorney, or advance directive. Community-level socioeconomic status was assessed using the Distressed Communities Index. Bivariable and multivariable analyses were performed., Results: We identified 424 patients: 104 (24.5%) of whom had ACP. Patients with ACP were older (64.8 versus 56.5 years, P = 0.001), more likely White (78.8% versus 71.9%, P = 0.057), and present with ASIA Impairment Scale grade A SCI (21.2% versus 12.8%, P = 0.054), although the latter two did not reach statistical significance. On multivariable logistic regression, patients residing in at-risk communities were significantly less likely to have ACP documents compared with those in prosperous communities (odds ratio [OR]: 0.29, P = 0.03). Although patients living in distressed communities were less likely to complete ACP compared with those in prosperous communities (OR 0.50, P = 0.066), this did not meet statistical significance. Female patients were also less likely to have ACP (OR: 0.43, P = 0.005)., Conclusion: Female patients and those from at-risk communities are markedly less likely to complete ACP. Attention to possible disparities during admission and ACP discussions may help ensure that patients of all backgrounds have treatment goals documented., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Study Design: Systematic Review., Objective: To review the literature for complications and outcomes after the implantation of cellular bone matrix (CBM) during spine fusion., Methods: The PubMed database was queried from inception to January 31, 2023 for any articles that discussed the role of and identified a specific CBM in spinal fusion procedures. Adverse events, reoperations, methods, and fusion rates were collected from all studies and reported., Results: Six hundred articles were identified, of which 19 were included that reported outcomes of 7 different CBM products. Seven studies evaluated lumbar fusion, 11 evaluated cervical fusion, and 1 study reported adverse events of a single CBM product. Only 4 studies were comparative studies while others were limited to case series. Fusion rates ranged from 68% to 98.7% in the lumbar spine and 87% to 100% in the cervical spine, although criteria for radiographic fusion was variable. While 7 studies reported no adverse events, there was no strict consensus on what constituted a complication. One study reported catastrophic disseminated tuberculosis from donor contaminated CBM. The authors of 14 studies had conflicts of interest with either the manufacturer or distributor for their analyzed CBM., Conclusions: Current evidence regarding the use of cellular bone matrix as an osteobiologic during spine surgery is weak and limited to low-grade non-comparative studies subject to industry funding. While reported fusion rates are high, the risk of severe complications should not be overlooked. Further large clinical trials are required to elucidate whether the CBMs offer any benefits that outweigh the risks., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: As the population of elderly patients continues to rise, the number of these individuals presenting with thoracolumbar trauma is expected to increase., Research Question: To investigate thoracolumbar fusion outcomes for patients with vertebral fractures as stratified by decade. Secondarily, we examined the variability of cost across age groups by identifying drivers of cost of care., Materials and Methods: We queried the United States Nationwide Inpatient Sample(NIS) for adult patients undergoing spinal fusion for thoracolumbar fractures between 2012 and 2017. Patients were stratified by decade 60-69(sexagenarians), 70-79(septuagenarians) and 80-89(octogenarians). Bivariable analysis followed by multivariable regression was performed to assess independent predictors of length of stay(LOS), hospital cost, and discharge disposition., Results: A total of 2767 patients were included, of which 46%(N = 1268) were sexagenarians, 36% septuagenarians and 18%(N = 502) octogenarians. Septuagenarians and octogenarians had shorter LOS compared to sexagenarians(ß = -0.88 days; p = 0.012) and(ß = -1.78; p < 0.001), respectively. LOS was reduced with posterior approach(-2.46 days[95% CI: 3.73-1.19]; p < 0.001), while Hispanic patients had longer LOS(+1.97 [95% CI: 0.81-3.13]; p < 0.001). Septuagenarians had lower total charges $12,185.70(p = 0.040), while the decrease in charges in octogenarians was more significant, with a decrease of $26,016.30(p < 0.001) as compared to sexagenarians. Posterior approach was associated with a decrease of $24,337.90 in total charges(p = 0.026). Septuagenarians and octogenarians had 1.72 higher odds(p < 0.001) and 4.16 higher odds(p < 0.001), respectively, of discharge to a skilled nursing facility., Discussion and Conclusions: Healthcare utilization in geriatric thoracolumbar trauma is complex. Cost reductions in the acute hospital setting may be offset by unaccounted costs after discharge. Further research into this phenomenon and observed racial/ethnic disparities must be pursued., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 Published by Elsevier B.V. on behalf of EUROSPINE, the Spine Society of Europe, EANS, the European Association of Neurosurgical Societies.)

Geriatric odontoid fractures are some of the most common spine injuries in our aging population, and their prevalence is only continuing to increase. Despite several investigational studies, treatment remains controversial and there is limited conclusive evidence regarding the management of odontoid fractures. These injuries typically occur in medically complex and frail geriatric patients with poor bone quality, making their treatment particularly challenging. In this article, we review the evidence for conservative management as well as surgical intervention and discuss various treatment strategies. Given the high morbidity and mortality associated with odontoid fractures in the elderly, thoughtful consideration and an emphasis on patient-centered goals of treatment are critical to maximize function in this vulnerable population., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Study Design: Retrospective single-institution cohort., Objective: To evaluate the implementation of a commercial bundled payment model in patients undergoing lumbar spinal fusion., Summary of Background Data: BPCI-A caused significant losses for many physician practices, prompting private payers to establish their own bundled payment models. The feasibility of these private bundles has yet to be evaluated in spine fusion., Methods: Patients undergoing lumbar fusion from October to December 2018 in BPCI-A before our institution's departure were included for BPCI-A analysis. Private bundle data was collected from 2018 to 2020. Analysis of the transition was conducted among Medicare-aged beneficiaries. Private bundles were grouped by calendar year (Y1, Y2, Y3). Stepwise multivariate linear regression was performed to measure independent predictors of net deficit., Results: The net surplus was the lowest in Y1 ($2,395, P =0.03) but did not differ between our final year in BPCI-A and subsequent years in private bundles (all, P >0.05). AIR and SNF patient discharges decreased significantly in all private bundle years compared with BPCI. Readmissions fell from 10.7% (N=37) in BPCI-A to 4.4% (N=6) in Y2 and 4.5% (N=3) Y3 of private bundles ( P <0.001). Being in Y2 or Y3 was independently associated with a net surplus in comparison to the Y1 (β: $11,728, P =0.001; β: $11,643, P =0.002). Postoperatively, length of stay in days (β: $-2,982, P <0.001), any readmission (β: -$18,825, P =0.001), and discharge to AIR (β: $-61,256, P <0.001) or SNF (β: $-10,497, P =0.058) were all associated with a net deficit., Conclusions: Nongovernmental bundled payment models can be successfully implemented in lumbar spinal fusion patients. Constant price adjustment is necessary so bundled payments remain financially beneficial to both parties and systems overcome early losses. Private insurers who have more competition than the government may be more willing to provide mutually beneficial situations where cost is reduced for payers and health systems., Level of Evidence: 3., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Approximately 9% of total joint arthroplasty (TJA) patients have pre-existing atrial fibrillation (AF). This study examined the effect of pre-existing AF on TJA outcomes., Methods: We conducted a 1:3 propensity match of 545 TJA patients who have pre-existing AF to TJA patients who do not have AF at a tertiary care center between January 1st, 2012, and January 1st, 2021. Bivariate and multivariate regressions were performed. Changes over time were evaluated., Results: Patients undergoing total knee arthroplasty (TKA) who have pre-existing AF, experienced more post-operative AFs (P < .001), acute kidney injuries (P = .026), post-operative complications (POC) (P < .001), and 30-day readmissions (P = .036). Patients undergoing total hip arthroplasty (THA) who have pre-existing AF experienced more post-operative AFs (P < .001), pulmonary embolisms (P < .001), increased estimated blood losses (P = .007), more blood transfusions (P = .002), more POCs (P < .001), and longer lengths of stay (LOS) (P < .002). Over time, POC and LOS decreased in both groups, but remained increased in TJA patients who have pre-existing AF. Multivariate analyses of TKA patients showed an increased odds ratio (OR) of any POCs (P < .001), while THA patients had an increased OR of any POCs (P = .01), and LOS (P = .002)., Conclusion: Patients who have pre-existing AF undergoing TJA have more POCs. TKA patients have more readmissions. THA patients have longer LOS. These findings demonstrate the importance of enhanced peri-operative medical management in patients who have pre-existing AF undergoing TJA., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Postoperative drains have long been regarded as a preventive measure to mitigate the risks of complications such as neurological impairment by reducing fluid accumulation following spine surgery. Our study aims to contribute to the existing body of knowledge by examining the effects of postoperative drain output on the 90-day postoperative outcomes for patients who experienced an incidental durotomy after lumbar decompression procedures, with or without fusion., Methods: All patients aged ≥18 years with an incidental durotomy from spinal decompression with or without fusion surgery between 2017 and 2021 were retrospectively identified. The patient demographics, surgical characteristics, method of dural tear repair (DuraSeal, suture, and/or DuraGen), surgical outcomes, and drain data were collected via medical record review. Patients were grouped by readmission status and final 8-hour drain output. Those with a final 8-hour drain output of ≥40 mL were included in the high drain output (HDO) group and those with <40 mL were in the low drain output (LDO) group., Results: There were no statistically significant differences in preoperative patient demographics, surgical characteristics, method of dural tear repair, length of stay (HDO, 4.02 ± 1.90 days; vs. LDO, 4.26 ± 2.10 days; P = 0.269), hospital readmissions (HDO, 10.6%; vs. LDO, 7.96%; P = 0.744), or occurrence of reoperation during readmission (HDO, 6.06%; vs. LDO, 2.65%; P = 0.5944) between the 2 groups., Conclusions: For patients undergoing primary lumbar decompression with or without fusion and experiencing an incidental durotomy, no significant association was found between the drain output and 90-day patient outcomes. Adequate fascial closure and the absence of symptoms may be satisfactory criteria for standard patient discharge regardless of drain output., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Study Design: Retrospective Cohort., Objective: To determine if outcomes varied between patients based on physical therapy (PT) attendance after lumbar fusion surgery., Summary of Background Data: The literature has been mixed regarding the efficacy of postoperative PT to improve disability and back pain, as measured by patient-reported outcome measures. Given the prevalence of PT referrals and lack of high-quality evidence, there is a need for additional studies investigating the efficacy of PT after lumbar fusion surgery to aid in developing robust clinical guidelines., Methods: We retrospectively identified patients receiving lumbar fusion surgery by current procedural terminology codes and separated them into 2 groups based on whether PT was prescribed. Electronic medical records were reviewed for patient and surgical characteristics, PT utilization, and surgical outcomes. Patient-reported outcome measures (PROMs) were identified and compared preoperatively, at 90 days postoperatively and one year postoperatively., Results: The two groups had similar patient characteristics and comorbidities and demonstrated no significant differences between readmission, complication, and revision rates after surgery. Patients that attended PT had significantly more fused levels (1.41 ± 0.64 vs. 1.32 ± 0.54, P =0.027), longer operative durations (234 ± 96.4 vs. 215 ± 86.1 min, P =0.012), and longer postoperative hospital stays (3.35 ± 1.68 vs. 3.00 ± 1.49 days, P =0.004). All groups improved similarly by Oswestry Disability Index, short form-12 physical and mental health subsets, and back and leg pain by Visual Analog Scale at 90-day and 1-year follow-up., Conclusion: Our data suggest that physical therapy does not significantly impact PROMs after lumbar fusion surgery. Given the lack of data suggesting clear benefit of PT after lumbar fusion, surgeons should consider more strict criteria when recommending physical therapy to their patients after lumbar fusion surgery., Level of Evidence: Level-Ⅲ., Competing Interests: Dr. Schroeder has received funds to travel from AO Spine and Medtronic. Dr. Vaccaro has consulted or has done independent contracting for DePuy, Medtronic, Stryker Spine, Globus, Stout Medical, Gerson Lehrman Group, Guidepoint Global, Medacorp, Innovative Surgical Design, Orthobullets, Ellipse, and Vertex. He has also served on the scientific advisory board/board of directors/committees for Flagship Surgical, AO Spine, Innovative Surgical Design, and Association of Collaborative Spine Research. Dr. Vaccaro has received royalty payments from Medtronic, Stryker Spine, Globus, Aesculap, Thieme, Jaypee, Elsevier, and Taylor Francis/Hodder and Stoughton. He has stock/stock option ownership interests in Replication Medica, Globus, Paradigm Spine, Stout Medical, Progressive Spinal Technologies, Advanced Spinal Intellectual Properties, Spine Medica, Computational Biodynamics, Spinology, In Vivo, Flagship Surgical, Cytonics, Bonovo Orthopaedics, Electrocore, Gamma Spine, Location Based Intelligence, FlowPharma, R.S.I., Rothman Institute and Related Properties, Innovative Surgical Design, and Avaz Surgical. He has also served as deputy editor/editor of Spine. In addition, Dr Vaccaro has also provided expert testimony. He has also served as deputy editor/editor of Clinical Spine Surgery. The remaining authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective cohort study., Objective: To determine the effects of discontinuity in care by changing surgeons, health systems, or increased time to revision surgery on revision spine fusion surgical outcomes and patient-reported outcomes., Summary of Background Information: Patients undergoing revision spine fusion experience worse outcomes than those undergoing primary lumbar surgery. Those requiring complex revisions are often transferred to tertiary or quaternary referral centers under the assumption that those institutions may be more accustomed at performing those procedures. However, there remains a paucity of literature assessing the impact of discontinuity of care in revision spinal fusions., Methods: Patients who underwent revision 1-3 level lumbar spine fusion 2011-2021 were grouped based on (1) revision performed by the index surgeon versus a different surgeon, (2) revision performed within the same versus different hospital system as the index procedure, and (3) length of time from index procedure. Multivariate regression for outcomes controlled for confounding differences., Results: A total of 776 revision surgeries were included. An increased time interval between the index procedure and the revision surgery was predictive of a lower risk for subsequent revision procedure (odds ratio: 0.57, P =0.022). Revision surgeries performed by the same surgeon predicted a reduced length of hospital stay (β: -0.14, P =0.001). Neither time to revision nor undergoing by the same surgeon or same practice predicted 90-day readmission rates. Patients are less likely to report meaningful improvement in Mental Component Score-12 or Physical Component Score-12 if revision surgery was performed at a different hospital system., Conclusions: Patients who have revision lumbar fusions have similar clinical outcomes regardless of whether their surgeon performed the index procedure. However, continuity of care with the same surgeon may reduce hospital length of stay and associated health care costs. The length of time between primary and revision surgery does not significantly impact patient-reported outcomes., Level of Evidence: Level III., Competing Interests: Dr. Schroeder has received funds to travel from AOSpine and Medtronic. Dr. Vaccaro has consulted or has done independent contracting for DePuy, Medtronic, Stryker Spine, Globus, Stout Medical, Gerson Lehrman Group, Guidepoint Global, Medacorp, Innovative Surgical Design, Orthobullets, Ellipse, and Vertex. He has also served on the scientific advisory board/board of directors/committees for Flagship Surgical, AO Spine, Innovative Surgical Design, and Association of Collaborative Spine Research. Dr. Vaccaro has received royalty payments from Medtronic, Stryker Spine, Globus, Aesculap, Thieme, Jaypee, Elsevier, and Taylor Francis/Hodder and Stoughton. He has stock/stock option ownership interests in Replication Medica, Globus, Paradigm Spine, Stout Medical, Progressive Spinal Technologies, Advanced Spinal Intellectual Properties, Spine Medica, Computational Biodynamics, Spinology, In Vivo, Flagship Surgical, Cytonics, Bonovo Orthopaedics, Electrocore, Gamma Spine, Location Based Intelligence, FlowPharma, R.S.I., Rothman Institute and Related Properties, Innovative Surgical Design, and Avaz Surgical. He has also served as deputy editor/editor of Spine. In addition, Dr Vaccaro has also provided expert testimony. He has also served as deputy editor/editor of Clinical Spine Surgery. The remaining authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Survey study., Objective: The objective of this study was to determine the impact of unexpected in-network billing on the patient experience after spinal surgery., Summary of Background Data: The average American household faces difficulty paying unexpected medical bills. Although legislative efforts have targeted price transparency and rising costs, elective surgical costs continue to rise significantly. Patients are therefore sometimes still responsible for unexpected medical costs, the impact of which is unknown in spine surgery., Methods: Patients who underwent elective spine surgery patients from January 2021 to January 2022 at a single institution were surveyed regarding their experience with the billing process. Demographic characteristics associated with unexpected billing situations, patient satisfaction, and financial distress, along with utilization and evaluation of the online price estimator, were collected., Results: Of 818 survey participants, 183 (22.4%) received an unexpected in-network bill, and these patients were younger (56.7 vs. 63.4 y, P <0.001). Patients who received an unexpected bill were more likely to feel uninformed about billing (41.2% vs. 21.7%, P <0.001) and to report that billing impacted surgical satisfaction (53.8% vs. 19.1%, P <0.001). However, both groups reported similar satisfaction postoperatively (Likert >3/5: 86.0% vs. 85.5%, P =0.856). Only 35 (4.3%) patients knew of the price estimator's existence. The price estimator was reported to be very easy or easy (N=18, 78.2%) to understand and very accurate (N=6, 35.3%) or somewhat accurate (N=8, 47.1%) in predicting costs., Conclusions: Despite new regulations, a significant portion of patients received unexpected bills leading to financial distress and affecting their surgical experience. Although most patients were unaware of the price estimator, almost all patients who did know of it found it to be easy to use and accurate in cost prediction. Patients may benefit from targeted education efforts, including information on the price estimator to alleviate unexpected financial burden., Competing Interests: G.D.S. has received funds to travel from AOSpine and Medtronic. Dr A.R.V. has consulted or has done independent contracting for DePuy, Medtronic, Stryker Spine, Globus, Stout Medical, Gerson Lehrman Group, Guidepoint Global, Medacorp, Innovative Surgical Design, Orthobullets, Ellipse, and Vertex. He has also served on the scientific advisory board/board of directors/committees for Flagship Surgical, AOSpine, Innovative Surgical Design, and Association of Collaborative Spine Research. Dr. A.R.V. has received royalty payments from Medtronic, Stryker Spine, Globus, Aesculap, Thieme, Jaypee, Elsevier, and Taylor Francis/Hodder and Stoughton. He has stock/stock option ownership interests in Replication Medica, Globus, Paradigm Spine, Stout Medical, Progressive Spinal Technologies, Advanced Spinal Intellectual Properties, Spine Medica, Computational Biodynamics, Spinology, In Vivo, Flagship Surgical, Cytonics, Bonovo Orthopaedics, Electrocore, Gamma Spine, Location Based Intelligence, FlowPharma, R.S.I., Rothman Institute and Related Properties, Innovative Surgical Design, and Avaz Surgical. In addition, Dr A.R.V. has also provided expert testimony. He has also served as deputy editor/editor of Clinical Spine Surgery. The remaining authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: This study is a retrospective cohort study., Purpose: This study aims to determine whether preoperative neuroforaminal stenosis (FS) severity is associated with motor function patient-reported outcome measures (PROMs) following anterior cervical discectomy and fusion (ACDF)., Overview of Literature: Cervical FS can significantly contribute to patient symptoms. While magnetic resonance imaging (MRI) has been used to classify FS, there has been limited research into the impact of FS severity on patient outcomes., Methods: Patients undergoing primary, elective 1-3 level ACDF for radiculopathy at a single academic center between 2015 and 2021 were identified retrospectively. Cervical FS was evaluated using axial T2-weighted MRI images via a validated grading scale. The maximum degree of stenosis was used for multilevel disease. Motor symptoms were classified using encounters at their final preoperative and first postoperative visits, with examinations ≤3/5 indicating weakness. PROMs were obtained preoperatively and at 1-year follow-up. Bivariate analysis was used to compare outcomes based on stenosis severity, followed by multivariable analysis., Results: This study included 354 patients, 157 with moderate stenosis and 197 with severe stenosis. Overall, 58 patients (16.4%) presented with upper extremity weakness ≤3/5. A similar number of patients in both groups presented with baseline motor weakness (13.5% vs. 16.55, p =0.431). Postoperatively, 97.1% and 87.0% of patients with severe and moderate FS, respectively, experienced full motor recovery (p =0.134). At 1-year, patients with severe neuroforaminal stenosis presented with significantly worse 12-item Short Form Survey Physical Component Score (PCS-12) (33.3 vs. 37.3, p =0.049) but demonstrated a greater magnitude of improvement (Δ PCS-12: 5.43 vs. 0.87, p =0.048). Worse stenosis was independently associated with greater ΔPCS-12 at 1-year (β =5.59, p =0.022)., Conclusions: Patients with severe FS presented with worse preoperative physical health. While ACDF improved outcomes and conferred similar motor recovery in all patients, those with severe FS reported much better improvement in physical function.

Objective: To establish the relationship between the magnitude of foraminal stenosis and 1) improvement in patient-reported outcomes, 2) improvement in motor function after lumbar decompression surgery, and 3) difference in surgical outcomes., Methods: Patients who underwent one-level posterior lumbar decompression for radiculopathy were retrospectively identified. Patient demographics and surgical characteristics were collected through a query search and manual chart review of the electronic medical records. Foraminal stenosis was determined on magnetic resonance imaging and graded using Lee et al.'s validated methodology as none, mild, moderate, or severe. Surgical outcomes, motor function, and patient-reported outcome measures (PROMs) were compared based on the amount of stenosis (mild vs. moderate vs. severe). Bivariant and multivariant analyses were performed., Results: Severe stenosis demonstrated more 90-day readmissions (0.00% vs. 0.00% vs. 8.57%, respectively, P = 0.019), though this effect did not remain significant on multivariate analysis (P = 0.068). There was no association between stenosis severity and the degree of functional impairment or PROMs preoperatively. Patients with moderate or severe preoperative foraminal stenosis showed improvement in all PROMs after surgery (P < 0.05) except the mental component of the Short Form 12 survey. Notably, central stenosis grade was insignificantly different between groups (P = 0.358). Multivariable logistic regression analysis did not identify any significant independent predictors of surgical outcomes or changes in PROMs., Conclusions: We demonstrated that regardless of foraminal stenosis severity preoperatively, patients have a similar improvement in PROMs, surgical outcomes, and restoration of motor function after lumbar decompression surgery for radiculopathy., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Although bundled payment models are well-established in Medicare-aged individuals, private insurers are now developing bundled payment plans. The role of these plans in spine surgery has not been evaluated. Our objective was to analyze the performance of a private insurance bundled payment program for lumbar decompression and microdiskectomy., Methods: A retrospective review was conducted of all lumbar decompressions in a private payer bundled payment model at a single institution from October 2018 to December 2020. 120-day episode of care cost data were collected and reported as net profit or loss regarding set target prices. A stepwise multivariable linear regression model was developed to measure the effect of patient and surgical factors on net surplus or deficit., Results: Overall, 151 of 468 (32.2%) resulted in a deficit. Older patients (58.6 vs. 50.9 years, P < 0.001) with diabetes (25.2% vs. 13.9%, P = 0.004), hypertension (38.4% vs. 28.4%, P = 0.038), heart disease (13.9% vs. 7.57%, P = 0.030), and hyperlipidemia (51.7% vs. 35.6%, P = 0.001) were more likely to experience a loss. Surgically, decompression of more levels (1.91 vs. 1.19, P < 0.001), posterior lumbar decompression (86.8% vs. 56.5%, P < 0.001), and performing surgery at a tertiary hospital (84.8% vs. 70.3%, P < 0.001) were more likely to result in loss. All readmissions resulted in a loss (4.64% vs. 0.0%, P < 0.001). On multivariable regression, microdiskectomy (β: $2,398, P = 0.012) and surgery in a specialty hospital (β: $1,729, P = 0.096) or ambulatory surgery center (β: $3,534, P = 0.055) were associated with cost savings. Increasing number of levels, longer length of stay, active smoking, and history of cancer, dementia, or congestive heart failure were all associated with degree of deficit., Conclusions: Preoperatively optimizing comorbidities and using risk stratification to identify those patients who may safely undergo surgery at a facility other than an inpatient hospital may help increase cost savings in a bundled payment model of working-age and Medicare-age individuals., Competing Interests: Conflicts of Interest and Source of Funding : The authors, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article. There are no relevant disclosures., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Patient-reported outcome measures (PROMs) assign objective measures to patient's subjective experiences of health, pain, disability, function, and quality of life. PROMs can be useful for providers in shared decision making, outcome assessment, and indicating patients for surgery. In this article, we provide an overview of the legacy PROMs used in spinal care, recent advancements in patient-reported outcomes, and future directions in PROMs. Recent advances in patient-reported outcome assessments have included standardization of measurement tools, integration of data collection into workflow, and applications of outcome measures in predictive models and decision-making tools. Continual appraisal of instruments and incorporation into artificial intelligence and machine learning analytics will continue to augment the delivery of high-value spinal care., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Background Context: Although incorporating patient reported outcomes (PROMs) into practice allows healthcare systems to evaluate the value of care provided, research and policy reflecting PROMs can only be valid if they represent all patients. Few studies have evaluated socioeconomic barriers to PROM completion, and none have done so in a spine patient population., Purpose: To identify patient barriers to PROM completion one year following lumbar spine fusion., Study Design/setting: Retrospective single-institution cohort study., Patient Sample: A total of 2,984 patients undergoing lumbar fusion between 2014 and 2020 OUTCOME MEASURES: Completion of Mental Component Score (MCS-12) and Physical Component Score (PCS-12) of Short Form-12 questionnaire 1 year postoperatively., Methods: A retrospective review was conducted of all patients undergoing 1-3-level lumbar fusion at a single urban tertiary center. PROMs were queried from our prospectively managed electronic outcomes database. Patients were considered to have complete PROMs if 1-year outcomes were available. Community-level characteristics were collected from patients' zip codes using the Economic Innovation Group Distressed Communities Index. Bivariate analyses were performed to assess factors associated with PROM incompletion along with multivariate logistic regression to control for confounders., Results: A total of 1,968 (66.0%) had incomplete 1-year PROMs. Patients with incomplete PROMs were more likely to be Black (14.5% vs 9.3%, p<.001), Hispanic (2.9% vs 1.6%, p=.027), reside in a distressed community (14.7% vs 8.5%, p<.001), and be active smokers (22.4% vs 15.5%, p<.001). On multivariate regression, Black race (OR: 1.46, p=.014, Hispanic ethnicity (OR: 2.19, p=.027), distressed community status (OR: 1.47, p=.024), workers' compensation status (OR: 2.82, p=.001), and active smoking (OR:1.31, p=.034) all were independently associated with PROM incompletion. Surgical characteristics, including primary surgeon, revision status, approach, and levels fused were not associated with PROM incompletion., Conclusions: Social determinants of health impact completion of PROMs. Patients completing PROMs are overwhelmingly White, non-Hispanic, and reside in wealthier communities. Efforts should be taken to provide better education regarding PROMs and ensure closer follow-up of certain subgroups of patients to avoid furthering disparities in PROM research., Competing Interests: Declaration of competing interest One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background Context: Bundled payment models require risk adjustment to ensure appropriate targets are set. While this may be standardized for many services, spine fusions demonstrate significant variability in approach, invasiveness, and use of implants, that may require further risk adjustment., Purpose: To evaluate variability in costs of spinal fusion episodes in a private insurer bundle payment program and identify whether current procedural terminology (CPT) code modifications are necessary for sustainable implementation., Study Design/setting: Retrospective single-institution cohort study., Patient Sample: A total of 542 lumbar fusion episodes in a private insurer bundled payment program from October 2018 to December 2020., Outcome Measures: A total of 120-day episode of care net surplus/deficit, 90-day readmissions, discharge disposition, and length of hospital stay., Methods: A review was conducted of all lumbar fusions in a single institution's payer database. Surgical characteristics (approach [posterior lumbar decompression and fusion (PLDF), transforaminal lumbar interbody fusion (TLIF), and circumferential fusion], levels fused, and primary vs revision) were collected from manual chart review. Episode of care cost data were collected as net surplus or deficit with respect to target prices. A multivariate linear regression model was constructed to measure the independent effects of primary versus revision, levels fused, and approach on the net cost savings., Results: Most procedures were PLDFs (N=312, 57.6%), single-level (N=416, 76.8%) and primary fusions (N=477, 88.0%). Overall, 197 (36.3%) resulted in a deficit, and were more likely to be three levels (7.11% vs 2.03%, p=.005), revisions (18.8% vs 8.12%, p<.001), and TLIF (47.7% vs 35.1%, p<.001) or circumferential fusions (p<.001). One-level PLDFs resulted in the greatest cost savings per episode ($6,883). Across both PLDFs and TLIFs, 3-level procedures resulted in significant deficit of -$23,040 and -$18,887, respectively. For circumferential fusions, 1-level fusions resulted in deficit of -$17,169 per case which rose to -$64,485 and -$49,222 for 2- and 3-level fusions. All 2- and 3-level circumferential spinal fusions resulted in a deficit. On multivariable regression, TLIF and circumferential fusions were independently associated with a deficit of -$7,378 (p=.004) and -$42,185 (p<.001), respectively. Three-level fusions were independently associated with an additional -$26,003 deficit compared to single-level fusions (p<.001)., Conclusions: Interbody fusions, especially circumferential fusions, and multi-level procedures are not adequately risk adjusted by current bundled payment models. Health systems may not be able to financially support these alternative payment models with improved procedure-specific risk adjustment., Competing Interests: Declaration of competing interest Dr. Vaccaro reports other from Advanced Spinal Intellectual Properties, personal fees from Aesculap, other from AO Spine, personal fees and other from Atlas Spine, other from Avaz Surgical, other from Bonovo Orthopaedics, other from Computational Biodynamics, other from Cytonics, other from Deep Health, other from Dimension Orthotics LLC, other from Electrocore, personal fees from Elsevier, other from Flagship Surgical, other from FlowPharma, personal fees and other from Globus, other from Innovative Surgical Design, personal fees and other from Jaypee, other from Jushi (Haywood) , personal fees from Medtronics, other from National Spine Health Foundation, other from Nuvasive, other from Orthobullets, other from Parvizi Surgical Innovation, other from Progressive Spinal Technologies, other from Replication Medica, other from Sentryx, other from Spine Medica, other from Spineology, other from Spine Wave, other from Stout Medical, personal fees from Stryker Spine, personal fees from Taylor Francis/Hodder and Stoughton, personal fees from Thieme, other from ViewFi Health, other from Accellus, other from AVKN Patient Driven Care, other from Harvard Medtech, outside the submitted work. And the other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: While patient reported outcome measures (PROMs) define value in spine surgery, several values such as minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) help guide the interpretation of PROMs and identify thresholds of clinical significance. Significant variation exists in reported values and their calculation, so the primary objective of this study was to systematically review the spine surgery literature for metrics of clinical significance derived from PROMs., Methods: We conducted a query of PubMed/MEDLINE and Scopus databases from inception to January 1, 2023, for studies that derived quantitative metrics (e.g., SCB, MCID, PASS) from PROMs in the setting of spine surgery with minimum 1-year follow-up. Details regarding the specific PROMs were collected including which PROM was measured, whether anchor- or distribution-based methods were utilized, the specific calculations, and the recommended value for a given PROM based on all evaluated calculations., Results: Thirty-seven studies of 21,780 patients were included. The most commonly evaluated PROM-derived value was the MCID (n = 28), followed by PASS (n = 6) and SCB (n = 4). Twenty-one studies only utilized anchor-based calculations, 15 utilized both anchor-based and distribution-based methods, and one only utilized distribution-based calculations. The most commonly evaluated legacy PROMs were the Oswestry Disability Index (ODI) (N = 11, MCID range 4-20) and visual analog scale back pain (N = 5, MCID range 0.5-4.6). All 10 studies that derived SCB or PASS utilized the receiver operating characteristic methods. Among the six studies deriving a PASS value, four only evaluated ODI, identifying PASS ranging from 5 to 22., Conclusion: While calculated measures of clinical significance such as MCID, PASS, and SCB exist, significant heterogeneity exists in the current literature. Current shortcomings include a wide variability of reported value thresholds across the literature, and limited applicability to more heterogenous patient populations than the targeted cohorts included in published investigations. Continued investigations that apply these methods to heterogenous, large-scale populations can help increase generalizability and validity of these measures., Level of Evidence: III., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Study Design: Retrospective cohort study., Objective: To determine the impact of multiple preoperative opioid prescribers on postoperative patient opioid usage and patient-reported outcome measures after single-level lumbar fusion., Summary of Background Data: Prior literature has identified opioid prescriptions from multiple postoperative providers increase opioid usage rates. However, there is limited evidence on how multiple preoperative opioid prescribers affect postoperative opioid usage or clinical outcomes after a single-level lumbar fusion., Patients and Methods: A retrospective review of single-level transforaminal lumbar interbody fusion or posterolateral lumbar fusions between September 2017 and February 2020 at a single academic institution was performed. Patients were excluded if they were not identifiable in our state's prescription drug-monitoring program. Univariate comparisons and regression analyses identified factors associated with postoperative clinical outcomes and opioid usage., Results: Of 239 patients, 160 (66.9%) had one or fewer preoperative prescribers and 79 (33.1%) had >1 prescribers. On regression analysis, the presence of multiple preoperative prescribers was an independent predictor of increased improvement in Visual Analog Scale (∆VAS) Back (β=-1.61, P =0.012) and the involvement of a nonoperative spine provider was an independent predictor of increased improvement in ∆VAS Leg (β = -1.53, P = 0.034). Multiple preoperative opioid prescribers correlated with an increase in opioid prescriptions postoperatively (β = 0.26, P = 0.014), but it did not significantly affect the amount of morphine milligram equivalents prescribed (β = -48.79, P = 0.146). A greater number of preoperative opioid prescriptions predicted worse improvements in VAS Back, VAS Leg, and Oswestry Disability Index and predicted increased postoperative opioid prescriptions, prescribers, and morphine milligram equivalents., Conclusions: Multiple preoperative opioid prescribers predicted increased improvement in postoperative back pain, whereas preoperative involvement of a nonoperative spine provider predicted improvements in leg pain after surgery. The number of preoperative opioid prescriptions was a better metric for predicting poor postoperative outcomes and increased opioid consumption compared with the number of preoperative opioid prescribers., Competing Interests: G.D.S. has received funds to travel from AO Spine and Medtronic. Dr Vaccaro has consulted or has done independent contracting for DePuy, Medtronic, Stryker Spine, Globus, Stout Medical, Gerson Lehrman Group, Guidepoint Global, Medacorp, Innovative Surgical Design, Orthobullets, Ellipse, and Vertex. He has also served on the scientific advisory board/board of directors/committees for Flagship Surgical, AO Spine, Innovative Surgical Design, and Association of Collaborative Spine Research. Dr Vaccaro has received royalty payments from Medtronic, Stryker Spine, Globus, Aesculap, Thieme, Jaypee, Elsevier, and Taylor Francis/Hodder and Stoughton. He has stock/stock option ownership interests in Replication Medica, Globus, Paradigm Spine, Stout Medical, Progressive Spinal Technologies, Advanced Spinal Intellectual Properties, Spine Medica, Computational Biodynamics, Spinology, In Vivo, Flagship Surgical, Cytonics, Bonovo Orthopaedics, Electrocore, Gamma Spine, Location Based Intelligence, FlowPharma, R.S.I., Rothman Institute and Related Properties, Innovative Surgical Design, and Avaz Surgical. In addition, Dr Vaccaro has also provided expert testimony. He has also served as deputy editor/editor of Clinical Spine Surgery. The remaining authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To examine ten-year trends in gender representation in speaking roles at major spine conferences., Background Context: Medical conferences play an important role in career opportunities. There is little analysis on gender representation of major spine conferences despite several studies demonstrating gender disparities within spine surgery., Study Design: Observational study., Sample: A total of 20,181 abstract speakers across 10 years of academic conferences for six spine societies., Outcome Measures: Percent of female abstract presenters., Materials and Methods: We collated the annual meeting programs of six major spine conferences (North American Spine Society (NASS), Scoliosis Research Society (SRS), International Meeting on Advanced Spine Techniques (IMAST), Global Spine Congress (GSC), American Association of Neurological Surgeons/Congress of Neurological Surgeons (AANS/CNS) Spine Summit, and the Cervical Spine Research Society (CSRS)) dating from 2013 to 2022. Departmental websites, society webpages, or personal social media were identified for images or the use of gendered pronouns in order to determine speaker gender for each speaker type. All categorical variables were compared using Pearson chi-square analysis., Results: Women constituted 1,816 (9.0%) of all 20,181 identified conference speakers. Female representation was highest at NASS (N=680, 12.2%) but lowest at CSRS (6.6%) and GSC (7.1%). Spine Summit (7.4%), IMAST (9.92%), and GSC (9.87%) demonstrated the largest annual percent increases in female representation. Institutions in Middle East and Africa (1.4%), and Central and South America (1.8%) supported the lowest percent of female speakers. Women were significantly less likely to be speakers or moderators/course faculty than to be podium abstract presenters (p<.001). The percent of women as invited speakers (10.4% vs. 5.5%, p=.001) and moderators (11.4% vs. 3.7%, p<.001) increased significantly over the study period, with annual increases of 8.8% and 20.8%, respectively, from 2013 to 2022 (p<.001)., Conclusions: While academic spine societies have made significant progress in promoting gender representation, especially among invited speakers and session moderators, women continue to be underrepresented compared to the percent of women in orthopedic surgery and neurosurgery., Competing Interests: Declaration of Competing Interest The authors, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article. There are no relevant disclosures., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To evaluate how preoperative anemia severity affects 90-day outcomes of spinal fusion surgery., Methods: A retrospective cohort study was conducted on adult lumbar fusion patients at a tertiary medical center. Patients were classified by World Health Organization anemia severity definitions for comparisons. Multivariate regression models were created to control for confounding variables, for all primary outcomes of transfusion requirements, non-home discharge, readmissions, complications, and length of stay., Results: A total of 2582 patients were included: 2.7% with moderate-severe anemia, 11.0% with mild anemia, and 86.3% without anemia. Moderate-severe patients had the longest hospital stay (5.03 days vs 4.14 and 3.59 days, p < 0.001) and highest risk of transfusion (52.2% vs 13.0% vs 2.69%, p < 0.001), non-home discharge (39.1% vs 27.8% vs 15.4%, p < 0.001), readmission (7.25% vs 5.99% vs 3.36%, p = 0.023), and complications (13.0% vs 9.51% vs 6.20%, p = 0.012). On multivariable logistic regression, both patients with mild and moderate-severe anemia had an increased risk of transfusion (OR: 37.3, p < 0.001; OR: 5.25, p < 0.001, respectively) and non-home discharge (OR: 2.00, p = 0.021; OR: 1.71, p = 0.001, respectively) compared to patients without anemia. Anemia severity was not independently associated with complications or 90-day readmission. On multivariable linear regression, mild anemia (β: 0.37, p = 0.001) and moderate-severe anemia (β: 1.07, p < 0.001) were independently associated with length of hospital stay., Conclusion: Patients with moderate-severe preoperative anemia are at increased risk for longer length of stay, transfusions, and non-home discharge. Improved optimization of preoperative anemia may significantly reduce healthcare utilization, and surgeons should consider these risks in preoperative planning., Level of Evidence: III., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Posterior cervical fusion (PCF) and anterior cervical diskectomy and fusion (ACDF) are two main surgical management options for the treatment of cervical spondylotic myelopathy. Although ACDF is less invasive than PCF which should theoretically reduce postoperative pain, it is still unknown whether this leads to reduced opioid use. Our objective was to evaluate whether PCF increases postoperative opioid use compared with ACDF., Methods: We retrospectively identified all patients undergoing 2-level to 4-level ACDF or PCF at a single center from 2017 to 2021. Our state's prescription drug-monitoring program was queried for filled opioid prescriptions using milligrams morphine equivalents (MMEs) up to 1 year postoperatively. In-hospital opioid use was collected from the electronic medical record. Bivariate statistics compared ACDF and PCF cohorts. Multivariate linear regression was done to assess independent predictors of in-hospital opioid use and short-term (0 to 30 days), subacute (30 to 90 days), and long-term (3 to 12 months) opioid prescriptions., Results: We included 211 ACDF patients and 91 PCF patients. Patients undergoing PCF used more opioids during admission (126.7 vs. 51.0 MME, P < 0.001) and refilled more MMEs in the short-term (118.2 vs. 86.1, P = 0.001) but not subacute (33.6 vs. 19.7, P = 0.174) or long-term (85.6 vs. 47.8, P = 0.310) period. A similar percent of patients in both groups refilled at least one prescription after 90 days (39.6% vs. 33.2%, P = 0.287). PCF (β = 56.7, P = 0.001) and 30-day preoperative MMEs (β = 0.28, P = 0.041) were associated with greater in-hospital opioid requirements. PCF (β = 26.7, P = 0.039), C5 nerve root irritation (β = 51.4, P = 0.019), and a history of depression (β = 40.9, P < 0.001) were independently associated with 30-day postoperative MMEs., Conclusions: PCF is initially more painful than ACDF but does not lead to persistent opioid use. Surgeons should optimize multimodal analgesia protocols to reduce long-term narcotic usage rather than change the surgical approach.Level of Evidence:III., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Spinal cord injury (SCI) is a leading cause of disability worldwide, and effective management is necessary to improve clinical outcomes. Many long-standing therapies including early reduction and spinal cord decompression, methylprednisolone administration, and optimization of spinal cord perfusion have been around for decades; however, their efficacy has remained controversial because of limited high-quality data. This review article highlights studies surrounding the role of early surgical decompression and its role in relieving mechanical pressure on the microvascular circulation thereby reducing intraspinal pressure. Furthermore, the article touches on the current role of methylprednisolone and identifies promising studies evaluating neuroprotective and neuroregenerative agents. Finally, this article outlines the expanding body of literature evaluating mean arterial pressure goals, cerebrospinal fluid drainage, and expansive duroplasty to further optimize vascularization to the spinal cord. Overall, this review aims to highlight evidence for SCI treatments and ongoing trials that may markedly affect SCI care in the near future., Competing Interests: Conflicts of Interest: The authors, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article. There are no relevant disclosures., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Study Design: Retrospective cohort study., Purpose: Our goal was to determine which radiographic images are most essential for degenerative spondylolisthesis (DS) classification and instability detection., Overview of Literature: The heterogeneity in DS requires multiple imaging views to evaluate vertebral translation, disc space, slip angle, and instability. However, there are several restrictions on frequently used imaging perspectives such as flexion-extension and upright radiography., Methods: We assessed baseline neutral upright, standing flexion, seated lateral radiographs, and magnetic resonance imaging (MRI) for patients identified with spondylolisthesis from January 2021 to May 2022 by a single spine surgeon. DS was classified by Meyerding and Clinical and Radiographic Degenerative Spondylolisthesis classifications. A difference of >10° or >8% between views, respectively, was used to characterize angular and translational instability. Analysis of variance and paired chi-square tests were utilized to compare modalities., Results: A total of 136 patients were included. Seated lateral and standing flexion radiographs showed the greatest slip percentage (16.0% and 16.7%), while MRI revealed the lowest (12.2%, p <0.001). Standing flexion and lateral radiographs when seated produced more kyphosis (4.66° and 4.97°, respectively) than neutral upright and MRI (7.19° and 7.20°, p <0.001). Seated lateral performed similarly to standing flexion in detecting all measurement parameters and categorizing DS (all p >0.05). Translational instability was shown to be more prevalent when associated with seated lateral or standing flexion than when combined with neutral upright (31.5% vs. 20.2%, p =0.041; and 28.1% vs. 14.6%, p =0.014, respectively). There were no differences between seated lateral or standing flexion in the detection of instability (all p >0.20)., Conclusions: Seated lateral radiographs are appropriate alternatives for standing flexion radiographs. Films taken when standing up straight do not offer any more information for DS detection. Rather than standing flexion-extension radiographs, instability can be detected using an MRI, which is often performed preoperatively, paired with a single seated lateral radiograph.

Purpose: To compare patient-reported and surgical outcome measures in patients with and without secondary shoulder stiffness (SSS) undergoing rotator cuff repair (RCR)., Methods: Patients undergoing rotator cuff repair from 2014 to 2020 with complete patient-reported outcome measures (PROMs) by the short-form 12 survey (SF-12) were retrospectively reviewed to identify if operative intervention for SSS was performed alongside the RCR. Those patients with operative intervention for SSS were propensity matched to a group without prior intervention for stiffness by age, sex, laterality, body mass index, diabetes mellitus status, and the presence of a thyroid disorder. The groups were compared by rotator cuff tear (RCT) size, surgical outcomes, further surgical intervention, rotator cuff retear rate, postoperative range of motion (ROM), and SF-12 results at 1 year after surgery. Delta values were calculated for component scores of the SF-12 and ROM values by subtracting the preoperative result from the postoperative result., Results: A total of 89 patients with SSS were compared to 156 patients in the control group at final analysis. The patients in the SSS group experienced a significant improvement in the delta mental health component score (MCS-12) of the SF-12 survey that was not seen in the control group ( P  = .005 to P  = .539). Both groups experienced significant improvement by the delta physical health component score (PCS-12) of the SF-12 survey (SSS: 7.68; P < .001; control: 6.95; P < .001). The SSS group also experienced greater improvement of their forward flexion (25.8° vs 12.9°; P  = .005) and external rotation (7.13° vs 1.65°; P  = .031) ROM than the control group., Conclusions: Operative intervention of SSS at the time of RCR has equivalent postoperative SF-12 survey outcome scores when compared to patients undergoing RCR without preoperative stiffness despite those patients having lower preoperative scores., Level of Evidence: Level III retrospective comparative study., (© 2023 Published by Elsevier Inc. on behalf of the Arthroscopy Association of North America.)

Background: Few studies regarding ossification of the posterior longitudinal ligament (OPLL) outside of Asia currently exist in the literature. A set of patients with multilevel cervical OPLL causing symptomatic myelopathy or radiculopathy from a North American sample is analyzed., Objective: The objective of this study was to describe the demographics, radiographic findings, and surgical outcomes of a cohort of North American patients with degenerative spondylosis presenting for operative management of multilevel (>3 segments) cervical OPLL., Materials and Methods: Forty-three patients diagnosed with multilevel cervical OPLL and degenerative spondylosis presenting with symptomatic cervical myelopathy or radiculopathy were surgically treated over a 9-year period at a single tertiary care academic medical center. Radiographic measurements were performed on preoperative computed tomography and magnetic resonance imaging images of the cervical spine. Clinical outcomes included pre- and postoperative Nurick scores, 90-day readmission, complication, and revision surgery rates., Results: The mean age was 66.1 ± 10.9 years with a mean latest follow-up time of 32.7 ± 16.4 months. Most patients had previous diagnoses of obesity (70.7%) and hypertension (55.8%). At least one-quarter of patients were diagnosed with type 2 diabetes (34.9%), hyperlipidemia (41.9%), cardiovascular disease (25.6%), or chronic kidney disease (25.3%). The most common OPLL subtype was segmental (39.5%) and spanned a mean of 3.54 ± 1.48 segments. Myelopathic symptoms were present in 88.4% of patients. All patients experienced significant neurologic improvement at 3-week and latest follow-up ( P < 0.001 for both)., Conclusions: Obesity, diabetes, and other metabolic derangements in patients with existing cervical spondylosis may be risk factors for a particularly aggressive form of multilevel OPLL. Various operative approaches may be employed to achieve adequate neurologic recovery. Further workup for OPLL in patients with these risk factors may prove beneficial to ensure appropriate operative management., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Journal of Craniovertebral Junction and Spine.)

Introduction: To improve price transparency, the Centers for Medicare & Medicaid Services (CMS) requires hospitals to post accessible pricing data for common elective procedures along with all third-party-negotiated rates. We aimed to evaluate hospital compliance with CMS regulations for both price estimators and machine-readable files for spinal fusions and to evaluate factors contributing to variability in hospital-negotiated pricing., Methods: We reviewed the top 100 orthopaedic hospitals ranked by US News & World Report to assess compliance with CMS price transparency regulations for all spine diagnosis-related groups. We recorded gross inpatient charge, cash price, and deidentified maximum and minimum rates for the 11 spine diagnosis-related groups (DRGs). Variability was compared with geographic practice costs (GPCI), expected Medicare reimbursements, and poverty rate and median income ratio., Results: Only 72% of hospitals were fully compliant in reporting spinal fusions on their price estimator, and 39% were fully compliant in reporting all mandatory rates for spinal fusions. The overall estimated cash price was $96,979 ± $56,262 and $62,595 ± $40,307 for noncervical and cervical fusion, respectively. Cash prices at top 50 hospitals were higher for both noncervical and cervical fusions ( P = 0.0461 and P = 0.0341, respectively). The average minimum negotiated rates ranged from 0.88 to 1.15 times the expected Medicare reimbursement, while maximum and cash prices were 3.41 to 3.90 and 2.53 to 4.08 times greater than Medicare reimbursement. GPCI demonstrated little to no correlation with DRG pricing. However, minimum negotiated rates and cash prices demonstrated weak positive correlations with the median income ratio and weak negative correlations with the poverty rate., Discussion: Most US hospitals are not fully compliant with CMS price transparency regulations for spinal fusions despite increased overall utilization of price estimators and machine-readable files. Although higher ranked hospitals charged more for spinal fusions, DRG prices remain widely variable with little to no correlation with practice cost or socioeconomic parameters., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Objective: In a retrospective cohort study, we compared the outcomes among clinical and radiographic degenerative spondylolisthesis (CARDS) subtypes for patients undergoing posterior lumbar decompression and fusion (PLDF) or transforaminal lumbar interbody fusion (TLIF) and evaluated the CARDS system as a tool to guide clinical decisions regarding the treatment of degenerative spondylolisthesis (DS)., Methods: Patients undergoing PLDF or TLIF for DS from 2010 to 2020 were identified. The patients were grouped by the preoperative CARDS classification. Multivariate analysis was used to determine the effects of the treatment approach on the 1-year patient-reported outcome measures (PROMs) and 90-day surgical outcomes., Results: A total of 1056 patients were included: 148 patients with type A DS, 323 with type B, 525 with type C, and 60 with type D. Patients with CARDS types A and C who underwent PLDF experienced a longer length of stay and were less likely to be discharged home. No differences were found in the incidence of revisions, complications, or readmissions between the surgical approaches. Patients with CARDS type A undergoing PLDF were less likely to achieve a minimal clinically important difference for back pain (36.8% vs. 76.7%; P = 0.013). No other significant differences were found in the PROMs among the CARDS subtypes. TLIF independently predicted for better leg pain improvement using the visual analog scale at 1 year of follow-up (β = -2.92; P = 0.017) for patients with CARDS type A. Multivariable analysis demonstrated no significant differences in PROMs by surgical approach among the other CARDS subtypes., Conclusions: Patients with disc space collapse and endplate apposition (CARDS type A) appear to benefit from TLIF. However, patients with lumbar spondylolisthesis without disc space collapse or kyphotic angulation (CARDS types B and C) showed no benefit from additional interbody placement., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: The objectives of our study were to (1) determine if physical therapy (PT) impacts patient-reported outcomes (PROMs) after lumbar decompression surgery and (2) determine if PT impacts postsurgical readmissions or reoperations after lumbar decompression surgery., Methods: Patients > 18 years of age who underwent primary one- or two-level lumbar decompression at our institution were identified. Patient demographics, surgical characteristics, surgical outcomes (all-cause 90 days readmissions and 90 days surgical readmissions), and patient-reported outcomes (PROMs) were compared between the groups. Multivariate linear regression was utilized to determine the individual predictors of 90 days readmissions and PROMs at the 1-year postoperative point. Alpha was set at P < 0.05., Results: Of the 1003 patients included, 421 attended PT postoperatively. On univariate analysis, PT attendance did not significantly impact 90-day surgical reoperations ( P = 0.225). Although bivariate analysis suggests that attendance of PT is associated with worse improvement in physical function ( P = 0.041), increased preoperative Visual Analogue Scale leg pain (0 = 0.004), and disability ( P = 0.006), as measured by the Oswestry Disability Index, our multivariate analysis, which accounts for confounding variables found there was no difference in PROM improvement and PT was not an independent predictor of 90-day all-cause readmissions ( P = 0.06). Instead, Charlson Comorbidity Index ( P = 0.025) and discharge to a skilled nursing facility ( P = 0.013) independently predicted greater 90-day all-cause readmissions., Conclusions: Postoperative lumbar decompression PT attendance does not significantly affect clinical improvement, as measured by PROMs or surgical outcomes including all-cause 90 days readmissions and 90-day surgical readmissions., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Journal of Craniovertebral Junction and Spine.)

Objective: To determine if dexamethasone administration reduced narcotic consumption during hospitalization and to evaluate if patients who received dexamethasone refilled fewer opioid prescriptions postoperatively., Methods: All adult patients who underwent primary elective 1- to 4-level anterior cervical discectomy and fusion at a single center were retrospectively identified. Prescription opioid use was collected from governmental online prescription drug monitoring programs, and in-hospital opioid use was collected from each patient's medication administration record and recorded as morphine milligram equivalents (MMEs). Patients were categorized by whether or not intravenous dexamethasone was administered perioperatively. Dexamethasone protocols were considered high dose if weight-based dosing was >0.20 mg/kg and low dose if <0.20 mg/kg. Multivariable linear regression was conducted to assess the relationship between dexamethasone administration and MMEs prescribed at each time point while accounting for confounders., Results: Of 249 included patients, 167 (67%) were administered dexamethasone. Patients in both groups used a similar quantity of opioids while hospitalized (no dexamethasone: 56.7 MMEs/day vs. dexamethasone: 39.4 MMEs/day, P = 0.350). Patients in both groups refilled a similar quantity of opioids in all postoperative time periods: 0-3 weeks (3.38 vs. 4.07 MMEs/day, P = 0.528), 3-6 weeks (0.36 vs. 0.75 MMEs/day, P = 0.198), 6-12 weeks (0.53 vs. 0.75 MMEs/day, P = 0.900), and 3 months to 1 year (0.28 vs. 0.43 MMEs/day, P = 0.531). On multivariable linear regression, dexamethasone was not associated with a reduction in opioid volume at any time point (all P > 0.05)., Conclusions: Administration of perioperative dexamethasone does not reduce in-hospital or home opioid usage regardless of weight-based dose. Analgesia should not be the primary driver of dexamethasone administration for anterior cervical discectomy and fusion., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Study Design: Systematic Review., Objectives: To systematically review the current literature and perform a meta-analysis on patients with cervical or lumbar spine Modic changes to determine if their baseline axial back pain and disability are comparable to patients without Modic changes., Methods: A systematic review of the PubMed database was conducted in accordance with PRISMA guidelines. A meta-analysis was performed to compare the mean differences in back pain, leg pain, and disability based on the presence of cervical or lumbar spine Modic changes. A subgroup analysis of the different types of Modic changes was conducted to determine if Modic type affected back pain or disability., Results: - After review of 259 articles, 17 studies were included for meta-analysis and ten studies were included for qualitative synthesis. In the lumbar spine, 10 high-quality studies analyzed Visual Analog Scale (VAS) back pain, 10 evaluated VAS leg pain, and 8 analyzed Oswestry Disability Index. VAS back pain (mean difference (MD), -.38; 95% CI, -.61 - .16) and Oswestry disability index (MD -2.52; 95% CI, -3.93 - -1.12) were significantly lower in patients without Modic changes. Modic change subtype was not associated with differences in patient-reported outcomes. Patients with cervical spine Modic changes did not experience more severe pain than those without MC., Conclusions: Modic changes in the lumbar spine are not associated with clinically significant axial low back pain severity or patient disability. Similar to the lumbar spine, Modic changes in the cervical spine are not associated with symptom severity, but they are associated with pain duration.

Introduction: The relationship between research productivity in training and future productivity as an attending spine surgeon is not well-established in the literature nor has the effect of geographic location of training institutions on future academic success been investigated. The aim of our study was to (1) summarize characteristics of academically productive spine surgeons, (2) assess predictors of long-term academic productivity, and (3) establish the effect of geographic location on long-term academic productivity., Methods: A query was conducted of the 2021 to 2022 North American Spine Society Spine Fellowship Directory of all orthopaedic and neurosurgical spine fellowship selection committee members for each institution participating in the spine fellowship match. The attending publication rate and h- index were determined. A multivariate linear regression model was developed. P value was set to <0.05., Results: We identified 310 orthopaedic and neurosurgical spine surgeons, representing 76 fellowship programs. Multivariate linear regression analysis identified that the publications during residency ( P < 0.001) and during fellowship ( P < 0.001) were significant predictors of an increased publication rate as an attending surgeon. By contrast, the preresidency publication rate ( P = 0.729) was not significantly predictive of the attending publication rate. Multivariate analysis of h- index found that residency publication rate had a positive correlation ( P = 0.031) compared with preresidency ( P = 0.579) or fellowship ( P = 0.257) rates. Attendings who had attended residency in the Northeast and currently practicing in the Northeast had a higher publication rate ( P < 0.001 and P = 0.004, respectively)., Discussion: A higher number of publications in residency and fellowship were markedly predictive of an increased publication rate as an attending spine surgeon. By contrast, preresidency publications may not be indicative of future academic productivity as an attending. Location may also contribute to attending publication rate and favor those who undergo residency training and ultimately practice in the Northeast., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Introduction: As an increasing number of lumbar fusion procedures are being conducted at specialty hospitals and surgery centers, appropriate patient selection and risk stratification is critical to minimizing patient transfers. Postoperative cardiac arrhythmia has been linked to worse patient outcomes and is a common cause of patient transfer. Therefore, we created a risk calculator to predict a patient's likelihood of developing a new-onset postoperative cardiac arrhythmia after lumbar spinal fusion, which may improve preoperative facility selection., Methods: A retrospective review was conducted of patients who undergoing lumbar fusion from 2017 to 2021 at a single academic center. Patients were excluded if they had any medical history of a cardiac arrhythmia. Multivariable regression was conducted to determine independent predictors of inpatient arrhythmias. The final regression was applied to a bootstrap to validate an arrhythmia prediction model. A risk calculator was created to determine a patient's risk of new-onset cardiac arrhythmia., Results: A total of 1,622 patients were included, with 45 patients developing a new-onset postoperative arrhythmia. Age (OR = 1.05; 95% CI, 1.02 to 1.09; P = 0.003), history of beta-blocker use (OR = 2.01; 95% CI, 1.08 to 3.72; P = 0.027), and levels fused (OR = 1.59; 95% CI, 1.20 to 2.00; P = 0.001) were all independent predictors of having a new-onset inpatient arrhythmia. This multivariable regression produced an area under the curve of 0.742. The final regression was applied to a bootstrap prediction modeling technique to create a risk calculator including the male sex, age, body mass index, beta-blocker use, and levels fused (OR = 1.04, [CI = 1.03 to 1.06]) that produced an area under the curve of 0.733., Conclusion: A patient's likelihood of developing postoperative cardiac arrhythmias may be predicted by comorbid conditions and demographic factors including age, sex, body mass index, and beta-blocker use. Knowledge of these risk factors may improve appropriate selection of an outpatient surgical center or orthopaedic specialty hospital versus an inpatient hospital for lumbar fusions., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Background Context: Demographic factors contribute significantly to spine surgery outcomes. Although race and ethnicity are not proxies for disease states, the intersection between these patient characteristics and socioeconomic status significantly impact patient outcomes., Purpose: The purpose of this study is to investigate the frequency of demographic reporting and analysis in randomized controlled clinical trials (RCTs) published in the three highest impact spine journals., Study Design: Systematic review., Patient Sample: We analyzed 278 randomized control trials published in The Spine Journal, Spine, and Journal of Neurosurgery: Spine between January 2012 - January 2022., Outcome Measures: Extracted manuscript characteristics included the frequency of demographic reporting, sample size, and demographic composition of studies., Methods: We conducted a systematic review of RCTs published between January 2012 - January 2022 in the three highest impact factor spine journals in 2021: The Spine Journal, Spine, and Journal of Neurosurgery: Spine. We determined if age, gender, BMI, race, and ethnicity were reported and analyzed for each study. The overall frequency of demographic reporting was assessed, and the reporting trends were analyzed for each individual year and journal. Among studies that did report demographics, the populations were analyzed in comparison to the national population per United States (US) census reports. Studies were evaluated for bias using Cochrane risk-of-bias., Results: Our search identified 278 RCTs for inclusion. 166 were published in Spine, 65 in The Spine Journal, and 47 in Journal of Neurosurgery: Spine. Only 9.35% (N=26) and 3.9% (N=11) of studies reported race and ethnicity, respectively. Demographic reporting frequency did not vary based on the publishing journal. Reporting of age and BMI increased over time, but reporting of race and ethnicity did not. Among RCTs that reported race, 88% were conducted in the US, and 85.71% of the patients in these US studies were White. White subjects were overly represented compared to the US population (85.71% vs. 61.63%, p<.001), and non-White or Black patients were most underrepresented (2.89% vs. 25.96%, p<.001)., Conclusions: RCTs published in the three highest impact factor spine journals failed to frequently report patient race or ethnicity. Among studies published in the US, study populations are increasingly represented by non-Hispanic White patients. As we strive to care for an increasingly diverse population and reduce disparities to care, spine surgeons must do a better job reporting these variables to increase the external validity and generalizability of RCTs., Competing Interests: Declaration of competing interest One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background Context: Reimbursement has slowly transitioned from a fee-for-service model to a bundled payment model after introduction of the United States Centers for Medicare and Medicaid Services bundled payment program. To minimize healthcare costs, some surgeons are trying to minimize healthcare expenditures by transitioning appropriately selected lumbar decompression patients to outpatient procedure centers., Purpose: To prepare a risk stratification calculator based on machine learning algorithms to improve surgeon's preoperative predictive capability of determining whether a patient undergoing lumbar decompression will meet inpatient vs. outpatient criteria. Inpatient criteria was defined as any overnight hospital stay., Study Design/setting: Retrospective single-institution cohort., Patient Sample: A total of 1656 patients undergoing primary lumbar decompression., Outcome Measures: Postoperative outcomes analyzed for inclusion into the risk calculator included length of stay., Methods: Patients were split 80-20 into a training model and a predictive model. This resulted in 1,325 patients in the training model and 331 into the predictive model. A logistic regression analysis ensured proper variable inclusion into the model. C-statistics were used to understand model effectiveness. An odds ratio and nomogram were created once the optimal model was identified., Results: A total of 1,656 patients were included in our cohort with 1,078 dischared on day of surgery and 578 patients spending ≥ 1 midnight in the hospital. Our model determined older patients (OR=1.06, p<.001) with a higher BMI (OR=1.04, p<0.001), higher back pain (OR=1.06, p=.019), increasing American Society of Anesthesiologists (ASA) score (OR=1.39, p=.012), and patients with more levels decompressed (OR=3.66, p<0.001) all had increased risks of staying overnight. Patients who were female (OR=0.59, p=.009) and those with private insurance (OR=0.64, p=.023) were less likely to be admitted overnight. Further, weighted scores based on training data were then created and patients with a cumulative score over 118 points had a 82.9% likelihood of overnight. Analysis of the 331 patients in the test data demonstrated using a cut-off of 118 points accurately predicted 64.8% of patients meeting inpatient criteria compared to 23.0% meeting outpatient criteria (p<0.001). Area under the curve analysis showed a score greater than 118 predicted admission 81.4% of the time. The algorithm was incorporated into an open access digital application available here: https://rothmanstatisticscalculators.shinyapps.io/Inpatient&#95;Calculator/?&#95;ga=2.171493472.1789252330.1671633274-469992803.1671633274 CONCLUSIONS: Utilizing machine-learning algorithms we created a highly reliable predictive calculator to determine if patients undergoing outpatient lumbar decompression would require admission. Patients who were younger, had lower BMI, lower preoperative back pain, lower ASA score, less levels decompressed, private insurance, lived with someone at home, and with minimal comorbidities were ideal candidates for outpatient surgery., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Although scientific researchers aim to present their projects at academic conferences as a step toward publication, not all projects mature to become a peer-reviewed manuscript. The publication rate of meetings can be utilized to assess the quality of presented research. Our objective was to evaluate the contemporary publication rate of abstracts presented at spine conferences., Methods: We reviewed annual meeting programs of North American Spine Society (NASS), Scoliosis Research Society (SRS), International Meeting on Advanced Spine Techniques (IMAST), Spine Global Spine Congress (GSC), Lumbar Spine Research Society (LSRS), and Cervical Spine Research Society (CSRS) from 2017 to 2019. Abstracts were identified as published from PubMed and Google search. From published manuscripts, journal name and open access status was collected. Journal impact factors were collected from the 2021 Journal Citation Reports., Results: A total of 3,091/5,722 (54%) abstracts were published, ranging from 44.5% to 66.3%. Publication rate of posters and podiums ranged from 39.8% to 64.8% and 51.6% to 67.2%, respectively. Podium presentations were more likely to be published than posters (59.6% vs. 47.2%, p<.001). Only NASS (61.4% vs. 61.8%) and LSRS (64.6% vs. 67.2%) demonstrated similar publication rates for posters and podiums. Award nominated abstracts had a significantly higher publication rate (68.0% vs. 53.4%, p<.001). Among journals with an impact factor, the median overall impact factor was 3.27 and was similar between all conferences except GSC, which was slightly lower (2.72 vs. 3.27, p<.001)., Conclusions: Fifty-four percent of abstracts were published with 3 societies (NASS, LSRS, and SRS) having rates of over 60%. Moreover, NASS and LSRS demonstrated high publication rates regardless of presentation type. These numbers are significantly higher than previous reports suggesting that these conferences allow attendees to review high quality evidence that is likely to achieve peer-reviewed publication while obtaining an early look at original research., Competing Interests: One or more of the authors declare financial or professional relationships on ICMJE-NASSJ disclosure forms., (© 2023 The Authors.)