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Study Design. Retrospective analysis of prospectively collected data. Objective. To evaluate how preexisting adjacent segment degeneration status impacts revision risk for adjacent segment disease (ASD) after lumbar fusions. Summary of Background Data. ASD incurs late reoperations after lumbar fusion surgeries. ASD pathogenesis is multifactorial. Preexisting adjacent segment degeneration, measured by Pfirrmann, is suggested as one of the predisposing factors. We sought to find deeper insights into this association by using a more granular degeneration measure, the combined imaging score (CIS). Patients and Methods. A total of 197 consecutive lumbar fusions for degenerative pathologies were enrolled in a prospective follow-up (median: 12 yr). Preoperative cranial adjacent segment degeneration status was determined using Pfirrmann and CIS, which utilize both radiographs and magnetic resonance imaging. On the basis of CIS, patients were trichotomized into tertiles (CIS < 7, CIS 7-10, and CIS >10). The cumulative ASD revision risk was determined for each tertile. After adjusting for age, sex, body mass index, sacral fixation, and fusion length, hazard ratios (95% CI) for ASD revisions were determined for each Pfirrmann and CIS score. Results. Patients in the intermediate CIS tertile had a cumulative ASD revision risk of 25.4% (17.0%-37.0%), while both milder degeneration (CIS < 7) [13.2% (6.5%-25.8%)] and end-stage degeneration (CIS > 10) [13.6% (7.0%-25.5%)] appeared to be protective against surgical ASD. Pfirrmann failed to show a significant association with ASD revision risk. Adjusted analysis of CIS suggested increased ASD revisions after CIS 7, which turned contrariwise after CIS 10. Conclusions. The effect of preexisting adjacent segment degeneration on ASD reoperation risk is not linear. The risk appears to increase with advancing degeneration but diminishes with endstage degeneration. Therefore, end-stage degenerative segments may be considered to be excluded from fusion constructs. [ABSTRACT FROM AUTHOR]

Background: Multiple techniques and pharmacological efforts have been tried to control intraoperative hemodynamic fluctuations, reduce perioperative blood loss and severe postoperative pain. This study aimed to assess the perioperative effects of oral premedication with pregabalin or clonidine for lumbar spine posterior fusion under general anesthesia (GA). Outcome measures: Perioperative blood loss, hemodynamics, anesthetics consumption, postoperative pain, and side effects Methods: This is a prospective, triple blinded randomized placebo-controlled trial (RCT). Ninety-six adult ASA I-II patients of either sex undergoing lumbar spine posterior fusion were randomly assigned to obtain a placebo (group E), pregabalin 300 mg (group P), or clonidine 200 μg (group C) orally 90 minutes before induction of GA. Trial registration: with (PACTR201710002416280). Results: Preemptive oral pregabalin 300 mg and clonidine 200 μg optimized intraoperative hemodynamics, reduced perioperative blood loss than the placebo group (by 22.2% and 30.7%, respectively), reduced postoperative pain scores, and anesthetic and postoperative analgesic consumption. In addition, they prolonged the duration to the first postoperative analgesic request. There was no major complication in any group. Conclusion: Premedication with pregabalin or clonidine reduced perioperative blood loss and optimized intraoperative and postoperative hemodynamics, with the preference for clonidine over pregabalin as well as both reduced postoperative pain scores, analgesic requirements, PONV, and shivering. Sedative drugs should be used in lower doses to avoid oversedation. Pregabalin-associated dizziness and visual disturbance may necessitate extra precautions and patient education. [ABSTRACT FROM AUTHOR]

Objective In the digital age, patients turn to online sources for lumbar spine fusion information, necessitating a careful study of large language models (LLMs) like chat generative pre-trained transformer (ChatGPT) for patient education. Methods Our study aims to assess the response quality of Open AI (artificial intelligence)’s ChatGPT 3.5 and Google’s Bard to patient questions on lumbar spine fusion surgery. We identified 10 critical questions from 158 frequently asked ones via Google search, which were then presented to both chatbots. Five blinded spine surgeons rated the responses on a 4-point scale from ‘unsatisfactory’ to ‘excellent.’ The clarity and professionalism of the answers were also evaluated using a 5-point Likert scale. Results In our evaluation of 10 questions across ChatGPT 3.5 and Bard, 97% of responses were rated as excellent or satisfactory. Specifically, ChatGPT had 62% excellent and 32% minimally clarifying responses, with only 6% needing moderate or substantial clarification. Bard’s responses were 66% excellent and 24% minimally clarifying, with 10% requiring more clarification. No significant difference was found in the overall rating distribution between the 2 models. Both struggled with 3 specific questions regarding surgical risks, success rates, and selection of surgical approaches (Q3, Q4, and Q5). Interrater reliability was low for both models (ChatGPT: k = 0.041, p = 0.622; Bard: k = -0.040, p = 0.601). While both scored well on understanding and empathy, Bard received marginally lower ratings in empathy and professionalism. Conclusion ChatGPT3.5 and Bard effectively answered lumbar spine fusion FAQs, but further training and research are needed to solidify LLMs’ role in medical education and healthcare communication.

Objective: In the digital age, patients turn to online sources for lumbar spine fusion information, necessitating a careful study of large language models (LLMs) like chat generative pre-trained transformer (ChatGPT) for patient education. Methods: Our study aims to assess the response quality of Open AI (artificial intelligence)'s ChatGPT 3.5 and Google's Bard to patient questions on lumbar spine fusion surgery. We identified 10 critical questions from 158 frequently asked ones via Google search, which were then presented to both chatbots. Five blinded spine surgeons rated the responses on a 4-point scale from 'unsatisfactory' to 'excellent.' The clarity and professionalism of the answers were also evaluated using a 5-point Likert scale. Results: In our evaluation of 10 questions across ChatGPT 3.5 and Bard, 97% of responses were rated as excellent or satisfactory. Specifically, ChatGPT had 62% excellent and 32% minimally clarifying responses, with only 6% needing moderate or substantial clarification. Bard's responses were 66% excellent and 24% minimally clarifying, with 10% requiring more clarification. No significant difference was found in the overall rating distribution between the 2 models. Both struggled with 3 specific questions regarding surgical risks, success rates, and selection of surgical approaches (Q3, Q4, and Q5). Interrater reliability was low for both models (ChatGPT: k = 0.041, p = 0.622; Bard: k = -0.040, p = 0.601). While both scored well on understanding and empathy, Bard received marginally lower ratings in empathy and professionalism. Conclusion: ChatGPT3.5 and Bard effectively answered lumbar spine fusion FAQs, but further training and research are needed to solidify LLMs' role in medical education and healthcare communication. [ABSTRACT FROM AUTHOR]

Diabetes predisposes to spine degenerative diseases often requiring surgical intervention. However, the statistics on the prevalence of spinal fusion success and clinical indications leading to the revision surgery in diabetes are conflicting. The purpose of the presented retrospective observational study was to determine the link between diabetes and lumbar spinal fusion complications using a database of patients (n  = 552, 45% male, age 54 ± 13.7 years) residing in the same community and receiving care at the same health care facility. Outcome measures included clinical indications and calculated risk ratio (RR) for revision surgery in diabetes. Paravertebral tissue recovered from a non-union site of diabetic and nondiabetic patients was analyzed for microstructure of newly formed bone. Diabetes increased the RR for revision surgery due to non-union complications (2.80; 95% CI, 1.12–7.02) and degenerative processes in adjacent spine segments (2.26; 95% CI, 1.45–3.53). In diabetes, a risk of revision surgery exceeded the RR for primary spinal fusion surgery by 44% (2.36 [95% CI, 1.58–3.52] vs 1.64 [95% CI, 1.16–2.31]), which was already 2-fold higher than diabetes prevalence in the studied community. Micro-CT of bony fragments found in the paravertebral tissue harvested during revision surgery revealed structural differences suggesting that newly formed bone in diabetic patients may be of compromised quality, as compared with that in nondiabetic patients. In conclusion, diabetes significantly increases the risk of unsuccessful lumbar spine fusion outcome requiring revision surgery. Diabetes predisposes to the degeneration of adjacent spine segments and pseudoarthrosis at the fusion sites, and affects the structure of newly formed bone needed to stabilize fusion. [ABSTRACT FROM AUTHOR]

• Pedicle Screw can cross the midline of the vertebrae without causing a pedicle screw breach. • Screw safety cone angle increase from L1 to L5. • L4 allows the most screw crossing from midline. Pedicle screw breach (PSB) is not uncommon following lumbar instrumentation, and in some instances, it may lead to vascular and/or neurologic complications. Previous literature suggested that screws crossing the vertebral midline on an anterior-posterior (AP) radiograph (or midsagittal on CT) are concerning for medial pedicle breach. Our primary aim was to map out the safe zones (SZ) of bilateral pedicle instrumentation and their relationship at each lumbar vertebral level. Our secondary aim was to evaluate the presence of SZs' intersection at each lumbar level, denoting safe midline pedicle screw crossing not otherwise associated with medial pedicle breach. Retrospective Anatomical Study. Adult patients in the from "The Cancer Imaging Archive" (TCIA) database who have not had thoraco-lumbo-sacral fusion. Physiologic measures obtained through 3D analysis of CT images and virtual pedicle screws. CT scans of 51 patients were randomly selected from "The Cancer Imaging Archive" (TCIA) online database for analysis. The Sectra 3D Spine software was used to create 3D renderings, place virtual screws, and make measurements. At each lumbar vertebra, the right and left pedicle corridors were mapped. At each pedicle, two screw positions were templated, the "medial limit screw" (MLS) and the "lateral limit screw" (LLS). Each limit screw was the most extreme position that the screw could exist in without causing a medial or lateral breach. The safe zone was defined as the zone between MLS and LLS. Measurements were taken for each level (between L1 and L5) and side (Left, Right). A total of 253 lumbar vertebrae from 51 patients (mean age 53.1, 56.9% male) were included. Two vertebrae from two patients were removed for poor image quality. Out of the 506 screw positions analyzed in our study, 97.4% had overlapping SZ and crossed the midplane without medial pedicle breach. The significant factors (p<.01) for safe midplane-crossing screws included: the screw length (L1–L5); the laterality of the screw entry point (L1–L4); and the pedicle diameter (L2 and L5). A midline crossing pedicle screw on a lumbar AP radiograph is not necessarily indicative of a medial pedicle screw breach. Anatomical (ie, larger pedicle diameter) and technical (ie, longer screws, and lateral entry points) factors allow for safety zone intersections and indicate safe midline crossing by pedicle screws. [ABSTRACT FROM AUTHOR]

Background Context: Lumbar spine fusion (LSF) surgery is a viable form of treatment for several spinal disorders. Treatment effects are preferably to be endorsed in real-life settings. Methods: This prospective study evaluated the 10-year outcomes of LSF. A population-based series of elective LSFs performed at 2 spine centers between January 2008 and June 2012 were enrolled. Surgeries for tumor, acute fracture, or infection, neuromuscular scoliosis, or postoperative conditions were excluded. The following patient-reported outcome measures (PROMs) were collected at baseline, and 1, 2, 5, and 10 years postsurgery: VAS for back and leg pain, ODI, SF-36. Longitudinal measures of PROMs were analyzed using mixed-effects models. Results: A total of 683 patients met the inclusion criteria, and 630 (92%) of them completed baseline and at least 1 follow-up PROMs, and they constituted the study population. Mean age was 61 (SD 12) years, 69% women. According to surgical indication, patients were stratified into degenerative spondylolisthesis (DS, n=332, 53%), spinal stenosis (SS, n=102, 16%), isthmic spondylolisthesis (IS, n=97, 15%), degenerative disc disease (DDD, n=52, 8%), and deformity (DF, n=47, 7%).All diagnostic cohorts demonstrated significant improvement at 1 year, followed by a partial loss of benefits by 10 years. ODI baselines and changes at 1 and 10 years were: (DS) 45, −21, and −14; (SS) 51, −24, and −13; (IS) 41, −24, and −20; (DDD) 50, −20, and −20; and (DF) 50, −21, and −16, respectively. Comparable patterns were seen in pain scores. Significant HRQoL achievements were recorded in all cohorts, greatest in physical domains, but also substantial in mental aspects of HRQoL. Conclusions: Benefits of LSF were partially lost but still meaningful at 10 years of surgery. Long-term benefits seemed milder with degenerative conditions, reflecting the progress of the ongoing spinal degeneration. Benefits were most overt in pain and physical function measures.

Introduction: This registry study aims to assess the prevalence and demographic characteristics of patients with lumbar spine (LS) surgical procedures who undergo total hip arthroplasty (THA), to compare the long-term survival and causes of failure of THA in patients who previously underwent LS fusion and non-fusion surgical procedures, and to evaluate the risk of undergoing a revision LS surgery after THA. Materials and methods: Patients who underwent LS surgery followed by THA were identified by cross-referencing data from the Orthopedic Prosthetic Implants Registry and the Regional Hospital Discharge Database. Three groups of THA patients were identified: patients who underwent previous lumbar surgery with fusion (LS fusion-THA), without fusion (LS non-fusion-THA), and a control group with only THA (No LS surgery–THA). Demographic data, THA survival, number and causes of failure, and data on revision procedures on THA and LS were collected. Results: Of the total of 79,984 THA, 2.2% of patients had a history of LS procedures. THA only patients showed better results, while patients in the LS fusion-THA group had worse implant survival at 5-year follow-up. In the LS fusion-THA and LS non-fusion-THA, mechanical THA failures were more frequent in the first two years after implantation. There were no differences between groups regarding the risk of undergoing LS revision surgery. Conclusions: LS surgery negatively affects THA survivorship. In patients who previously underwent LS fusion and non-fusion surgical procedures, most THA failure occurs in the first two years after implant. The study contributes to the understanding of the relationship between the hip and the LS and provides useful guidance for clinical practice. [ABSTRACT FROM AUTHOR]

Background: In patients with concomitant hip and lumbar spine disease, the question of which surgery—total hip arthroplasty (THA) or lumbar spine fusion (LSF)—to address first has not been adequately answered. We aimed to evaluate the risk of dislocation after THA in patients with LSF first or after THA. Methods: Retrospective review utilizing the PearlDiver database querying Current Procedural Terminology codes for LSF in the year prior (LSF first) or in the year after primary or revision THA (THA first). International Classification of Disease codes identified postoperative hip dislocation as our primary outcome variable. Demographic data collected included age, sex, and obesity. Dislocation rates were described as a proportion of the cohort and compared with chi-square tests. Results: We identified 280,857 primary THA and 42,314 revision THA cases from 2012-2019. Of these, 2090 underwent primary THA and LSF, and 283 underwent revision THA and LSF within a year of each procedure. No differences in age, sex, or obesity between groups were noted. No difference in rate of all-time dislocation for primary THA was noted for the LSF first 51/1429 (3.6%) compared to the THA first 30/661 (4.0%) groups (P = .34), or for revision THA with LSF first 48/204 (23.5%) compared to THA first 27/117 (23.1%) groups (P = 1.0). Conclusions: There was no difference in the risk of dislocation after primary or revision THA if LSF occurred prior to or after the THA. These findings can help surgeons as they counsel patients with concomitant lumbar spine and hip degeneration.

Study Design: Retrospective observational cohort. Objectives: We sought to evaluate the impact of ESR on in-hospital and 90-day postoperative opioid consumption, length of stay, urinary catheter removal and postoperative ambulation after lumbar fusion for degenerative conditions. Methods: We evaluated patients undergoing lumbar fusion surgery at a single, multi-surgeon center in the transition period prior to (N = 174) and after (N = 116) adoption of ESR, comparing in-hospital and 90-day postoperative opioid consumption. Regression analysis was used to control for confounders. Secondary analysis was preformed to evaluate the association between ESR and length of stay, urinary catheter removal and ambulation after surgery. Results: Mean age study participants was 52.6 years with 62 (47%) females. Demographic characteristics were similar between the Pre-ESR and ESR groups. ESR patients had better 3-month pain scores, ambulated earlier, had urinary catheters removed earlier and decreased in-hospital opioid consumption compared to Pre-ESR patients. There was no difference in 90-day opioid consumption between the 2 groups. Regression analysis showed that ESR was strongly associated with in-hospital opioid consumption, accounting for 30% of the variability in Morphine Milligram Equivalents (MME). In-hospital opioid consumption was also associated with preoperative pain scores, number of surgical levels, and insurance type (private vs government). Pre-op pain sores were associated with 90-day opioid consumption. Secondary analysis showed that ESR was associated with a shorter length of stay and earlier ambulation. Conclusions: This study showed ESR has the potential to improve recovery after lumbar fusion for degenerative conditions with reduced in-hospital opioid consumption and improved postoperative pain scores. [ABSTRACT FROM AUTHOR]

Purpose: Bone graft extenders have been developed to prevent donor site morbidity associated with iliac crest bone graft, but few studies compared the efficacy of various substitutes. Our purpose was to determine fusion rate and clinical outcome in patients undergoing lumbar arthrodesis using demineralized bone matrix (DBM) and biphasic calcium phosphate (BCP). Methods: Patients with degenerative spondylolisthesis undergoing one-level or two-level arthrodesis of lumbar spine were retrospectively reviewed. Two treatment groups placed either BCP or DBM, in addition to local autograft in lumbar posterolateral space. Three-dimensional CT exam and dynamic flexion–extension radiographs at postoperative 2-year were assessed for posterolateral fusion status and pain scale and Oswestry Disability Index (ODI) for clinical outcome. Results: Of the 148 patients reviewed (including 23 in one- and 58 patients in two-level in BCP group, and 47 in one- and 20 patients in two-level in DBM group), no significant differences were found in terms of age, sex, BMI, smoking, diabetes, steroids, number of level fused, non-union rate or revision surgery between BCP and DBM groups. Significantly improved pain scale of back and leg and ODI were found in both groups postoperatively without group difference. We found a comparable fusion rate in one-level surgery (100% versus 93.6%) and a superior fusion rate of BCP group in two-level surgery (98.3% versus 80.0%, p = 0.01). Conclusion: Being a bone graft extender without osteoinductive property, with local autograft, BCP is comparable to DBM for one- and superior for two-level fusion. No significant difference was found in clinical outcomes. [ABSTRACT FROM AUTHOR]

Purpose: Anterior lumbar spine arthrodesis has been increasingly prescribed. In order to obtain better exposure of the intervertebral discs, it is necessary to identify vascular structures depending on the level to be approached. Systematic ligation of the iliolumbar vein has been suggested for access to the L4–L5 level, which may be technically challenging. The goal of the present study was to determine a safe limit for separating the iliolumbar vein safely without the need for its ligation. Methods: In total, 2284 patients involving the topography of the iliolumbar vein were included. If this vein was up to 5 mm distant from the inferior border of the L4–L5 intervertebral disc, its ligature was performed. In cases that the distance was greater than 5 mm, only the retraction was performed without ligature. Results: A total of 115 ligatures were necessary (5% of cases). Among the 2169 cases with no ligature, bleeding due to ruptures occurred during traction in only 55 patients (3% of cases). The time taken for ligation ranged from five minutes to thirty-two minutes, with an average of 18.3 min per ligature. In cases in which ligatures were needed (distance less than 5 mm), there was loosening of the ligatures leading to bleeding in 23 cases (20% of ligatures). Conclusions: Systematic ligature is not necessary for accessing the anterior route to the L4–L5 level, leading to a reduction in the time of surgery and avoiding serious vascular injuries that can occur. [ABSTRACT FROM AUTHOR]

Background: We compared the characteristics, comorbidities, and complications in spinal deformity patients with and without multiple sclerosis (MS) undergoing primary lumbar spine fusion. Methods: We used the Nationwide Inpatient Sample (NIS) from 2003 to 2014, International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedure codes to create experimental MS (842 patients) and non-MS control (165,726 patients) cohorts undergoing primary lumbar spine fusion. Characteristics, comorbidities, and complications in spinal deformity patients with and without MS were evaluated using univariate and bivariate analysis. Results: MS spinal deformity patients undergoing primary lumbar spine fusion were younger, more likely to be female and more likely to undergo surgery at urban teaching hospitals. They also exhibited higher rates of depression and lower rates of diabetes without chronic complications, hypertension, and renal failure. However, no significant differences were found in mortality or total perioperative complication rates between MS and non-MS patients. Conclusion: We found that MS versus non-MS patients undergoing primary lumbar fusion for spinal deformity were younger, more likely to be female and had higher rates of depression but lower rates of diabetes, hypertension, and renal failure. Notably, both groups experienced comparable mortality and perioperative complication rates. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective additional analysis of a prospective follow-up study.Objectives: We aimed to find out whether poor postoperative sagittal alignment increases revisions for adjacent segment disease (ASD) after lumbar spine fusion (LSF) performed for degenerative lumbar spine disease.Summary Of Background Data: Revisions for ASD accumulate over time after LSF for degenerative lumbar spine disease. The etiology of ASD is considered multifactorial. Yet, the role of postoperative sagittal balance in this process remains controversial.Materials and Methods: A total of 215 consecutive patients who had undergone an elective LSF surgery for spinal stenosis with (80%) or without (20%) spondylolisthesis were analyzed. Spinal reoperations were collected from the hospital records. Preoperative and postoperative sagittal alignment were evaluated from standing radiographs. The risk of revisions for ASD was evaluated by Cox proportional hazards regression models.Results: We did not find the poor postoperative balance [pelvic incidence-lumbar lordosis (LL) >9°] to significantly increase the risk of revisions for ASD: crude hazard ratio (HR)=1.5 [95% confidence interval (CI): 0.8-2.7], adjusted (by age, sex, pelvic incidence, fusion length, and the level of the caudal end of fusion): HR=1.7 (95% CI: 0.9-3.3). We found higher LL outside the fusion segment (LL-segmental lordosis) to decrease the risk of revisions for ASD: HR=0.9 (95% CI: 0.9-1.0).Conclusion: Poor sagittal balance has only a limited role as a risk factor for the revisions for ASD among patients with degenerative spinal disease. However, the risk for ASD might be the greatest among patients with reduced spinal mobility. [ABSTRACT FROM AUTHOR]

Depression and Degenerative Spine Disease (DSD) frequently co-exist. Pooled prevalence estimates of depression before and after lumbar fusion surgery has not been analyzed before. The purpose of this systematic review was to estimate the pre- and post-operative prevalence of depression in patients with DSD undergoing lumbar fusion. A literature review until April 30th 2022 was performed. All studies on DSD patients undergoing lumbar spine fusion surgery with either a history of formal diagnosis of depression or a recording of depression using a validated tool were included. Patients with other psychiatric conditions or undergoing a different form of spinal surgery were excluded. Risk of bias of the included studies was evaluated using the Newcastle-Ottawa Scale. Fifteen (15) studies with a total of 98.375 patients met the inclusion and exclusion criteria and were included in the analysis. The prevalence estimate of depression in patients before surgery was 15,35 % (95% CI: 10,56–20,86%). In the 7 studies including patients who had undergone lumbar fusion, the pooled prevalence was estimated 11,46% (95% CI: 8,11–15,30%). An increased prevalence of depression in patients undergoing lumbar spine fusion was noted. Given the correlation between depression and poor surgical outcomes, strategies should be identified to prevent and treat depression in these patients. [ABSTRACT FROM AUTHOR]

Background: Elderly patients frequently suffer from multi-level degenerative lumbar spondylolisthesis/stenosis, particularly heavy labor workers, farmers, and obese individuals. The gold standard of treatment is surgical fusion following failure of conservative management; however, long-segment fusion wounds can cause premature adjacent segment disease. Owing to improved techniques and equipment, endoscopic spine surgery, lumbar spine fusion, laminectomy, or discectomy can be performed with a single or biportal spinal endoscope. We attempted to use these endoscopic techniques to decrease the fusion level in long-segment degenerative lumbar spines. Our strategy was to only fuse the most severe central and foraminal spondylolisthesis levels and arrange for endoscopic decompression only (without fusion) in other central stenosis spondylolisthesis levels. Methods: From September 2019 to May 2021, we enrolled 14 patients (average age 72 [9 females, 5 males]) with long-segment (>3 segments) low-grade spondylolisthesis and spinal stenosis who required spinal fusion after failed conservative treatment. We performed anterior lumbar interbody fusion or endoscopic-transforaminal lumbar interbody fusion for spondylolisthesis with central and foraminal stenosis levels only, particularly those involving the lowest segment; the endoscopic unilateral approach and bilateral decompressions were performed for other cephalic spondylolisthesis with central stenosis levels. Results: At the 1-year after hybrid operation, the patient’s daily function and neurologic pain have significant improvement. No major complications occurred during follow-up. There was no significant lumbar lordosis change, vertebral slip distance progression or range of motion change, even in vertebrae adjacent to the fusion level. Conclusions: Performing multiple levels of endoscopic decompression above the fusion level is a reliable alternative technique that does not negatively impact spine structural stability.

Purpose: The effectiveness of a 12-month home-exercise program on trunk muscle strength after lumbar spine fusion surgery was evaluated. Three months postoperatively, 98 patients were randomized either to the exercise group (EG), with a progressive 12-month home-based exercise program, or to usual care group (UCG), with one guidance session for light home-exercises. Maximal trunk muscle strength was measured by a strain-gauge dynamometer and trunk extensor endurance was measured by Biering-Sørensen's test at baseline and after the intervention. The mean change in extension strength during the intervention was 75 N in EG and 58 N in UCG. Flexion strength improved 50 N in UCG and 45 N in EG. Trunk extension/flexion strength ratio changed from 0.90 to 1.02 in EG and from 0.98 to 1.00 in UCG. In EG, Biering-Sørensen's test improved by 17 s, and in UCG, it improved by 24 s. No statistically significant between-group differences were found in any variables. Median exercise frequency in EG decreased from 2.5×/week during the first two intervention months to 1.7×/week during the last two intervention months. Twelve-month progressive exercise program was equally effective as usual care in improving trunk muscle strength. Home exercise adherence decreased, which may have influenced the strength changes. The 12-month home-based exercise program was equally as effective as usual care after lumbar spine fusion (LSF) in improving trunk muscle strength, however, the back-specific exercises led to better trunk muscle strength balance in exercise group only. The adherence to the home based exercise program is a challenge; therefore, different techniques could be implemented to provide purposeful support for each individual in their long-term exercising. It is important to recognize those who need more individualized rehabilitation in recovery of the spine function, while others may manage with subtle intervention after LSF. [ABSTRACT FROM AUTHOR]

Study Design: Prospective, follow-up study.Objective: We aim to compare the rate of revisions for ASD after LSF surgery between patients with IS and DLSD.Summary Of Background Data: ASD is a major reason for late reoperations after LSF surgery. Several risk factors are linked to the progression of ASD, but the understanding of the underlying mechanisms is imperfect. If IS infrequently becomes complicated with ASD, it would emphasize the role of the ongoing degenerative process in spine in the development of ASD.Methods: 365 consecutive patients that underwent elective LSF surgery were followed up for an average of 9.7 years. Surgical indications were classified into 1) IS (n = 64), 2) DLSD (spinal stenosis with or without spondylolisthesis) (n = 222), and 3) other reasons (deformities, postoperative conditions after decompression surgery, posttraumatic conditions) (n = 79). All spinal reoperations were collected from hospital records. Rates of revisions for ASD were determined using Kaplan-Meier methods.Results: Altogether, 65 (17.8%) patients were reoperated for ASD. The incidences of revisions for ASD in subgroups were 1) 4.8% (95% CI: 1.6%-22.1%); 2) 20.5% (95% CI: 15.6%-26.7%); 3) 20.6% (95% CI: 12.9%-31.9%). After adjusting the groups by age, sex, fusion length, and the level of the caudal end of fusion, when comparing with IS group, the other groups had significantly higher hazard ratios (HR) for the revision for ASD [2) HR (95% CI) 3.92 (1.10-13.96), P = 0.035], [3) HR (95% CI) of 4.27 (1.11-15.54), P = 0.036].Conclusion: Among patients with IS, the incidence of revisions for ASD was less than a 4th of that with DLSD. Efforts to prevent the acceleration of the degenerative process at the adjacent level of fusion are most important with DLSD.Level of Evidence: 3. [ABSTRACT FROM AUTHOR]

Introduction: Transforaminal lumbar interbody fusion (TLIF) surgery is well established for the treatment of discopathy, foraminal disc herniation, and recurrent disc herniation. At the Amiens university medical center, we have been using a robot-assisted technique for performing the TLIF. The purpose of this study is to evaluate the radiological and clinical outcome, specifically pain, of patients having undergone robot-assisted TLIF. Materials and Methods: We performed a retrospective analysis of prospectively collected data of patients having undergone minimally invasive (MI) robot-assisted TLIF between November 2014 and July 2018 in a French university medical center. In clinical consultations at 6 weeks, 12 months, and 24 months posttreatment, patients were assessed for back and leg pain (on a visual analog scale), breached screws, and sagittal parameters. Results: A total of 136 pedicle screws were inserted with robot guidance into 32 patients. Four of the patients required laminectomy before fusion. No pedicle breach occurred for 94% of the screws, and no joint violation was observed for 90%. Lordosis was improved in 78% of the cases. Conclusions: The robot provides valuable assistance during MI arthrodesis; it facilitates the surgical procedure by preplanning the trajectory, providing instantaneous navigation and tracking, and thus assure the accuracy of screw positioning. [ABSTRACT FROM AUTHOR]

• Adverse outcomes after lumbar fusion surgery does not increase due to age alone. • Patients over 70 are more likely to be discharged to an inpatient rehabilitation. • Patients over 70 are more likely to receive a perioperative blood transfusion. Age is an important patient characteristic that has been correlated with specific outcomes after lumbar spine surgery. We performed a retrospective cohort study to model the effect of age on discharge destination and complications after a 1-level or multi-level lumbar spine fusion surgery. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients who underwent lumbar spinal fusion surgery from 2013 through 2017. Perioperative outcomes were compared across ages 18 to 90 using multivariable nonlinear logistic regression controlling for preoperative characteristics. A total of 61,315 patients were analyzed, with patients over 70 having a higher risk of being discharged to an inpatient rehabilitation center and receiving an intraoperative or postoperative blood transfusion. However, the rates of the other complications and outcomes analyzed in this study were not significantly different as patients age. In conclusion, advanced-age affects the discharge destination after a one- or multi-level fusion and intraoperative/postoperative blood transfusion after a one-level fusion. However, age alone does not significantly affect the risk of the other complications and outcomes assessed in this study. This study will help guide preoperative discussion with advanced-aged patients who are considering a 1-level or multi-level lumbar spine fusion surgery. [ABSTRACT FROM AUTHOR]

Objective: To compare the patient-reported outcomes (PROs) between patients undergoing multilevel lumbar fusion with robot-assisted vs. freehand techniques. Methods: This was a single-institution cohort study of adult patients (≥18 years old) undergoing robot-assisted spine surgery from 2016 to 2018 with minimum 2-year follow-up. A propensity-score matching (PSM) algorithm accounted for several perioperative factors. PROs were measured using the Oswestry Disability Index (ODI). The minimum clinically important difference (MCID) between groups were assessed at each follow-up period (6-weeks/6-months/1-year/2-years). Chi-square/fisher exact test and t-test/ANOVA were used for categorical and continuous variables, respectively. Results: After PSM, a total of 70 patients remained. The mean (standard deviation) charlson comorbidity index was 1.4 (1.0) and 57% of patients were female. The most common diagnoses included degenerative disc disease (37.1%), degenerative scoliosis (27.1%), and high grade spondylolisthesis (grade > 2) (19%), and the mean number of instrumented levels was 4.6 (4.4). Rates for intraoperative/postoperative complications, and any reoperation within 2 years after surgery were low and similar between groups. The baseline ODI scores were similar between freehand (39.1) and robot-assisted surgery (40.5, P-value = 0.736). By two years, substantial improvements in both groups (mean ODI-freehand: 4.6, robot-assisted: 1.5; MCID%-freehand: 77.1%, robot-assisted: 82.9%) were achieved, but not significantly different (P-value > 0.05). No differences were observed for the other follow-up periods. When comparing individual component scores, the robot-assisted group scored higher in “Lifting,” “Sitting,” and “Standing;” however, the magnitudes of these differences were less than 1 point. Conclusion: Robot-assisted multi-level lumbar fusion can achieve excellent and similar patient-reported outcomes to conventional freehand techniques. Future studies should include large, prospective randomized controlled trials as well as the inclusion of other patient reported outcome measures.

Study Design: Retrospective, comparative.Objective: The aim of this study was to design an enhanced recovery after surgery (ERAS) protocol for elective lumbar spine fusion by posterior approach, and to compare the results after ERAS implementation in patients undergoing elective lumbar spine fusion with conventional perioperative care.Summary Of Background Data: Despite wide adoption in other surgical disciplines, ERAS has only been recently implemented in spine surgery. The integrated multidisciplinary approach of ERAS aims to reduce surgical stress to achieve better outcomes.Methods: Hospital records of adult patients who underwent one- to three-level elective lumbar spine fusion by posterior approach at a single center were retrospectively studied. An ERAS protocol was designed based on the prevalent hospital practices, local resources and supportive evidence from literature. The ERAS protocol was implemented at our institute in December 2016-dividing patients into pre-ERAS and post-ERAS groups. The outcome measures for comparison were: length of hospital stay (LOS), postoperative complications, 60-day readmission rate, 60-day reoperation rate, and patient-reported outcome measures (visual analogue scale [VAS] and Oswestry Disability Index [ODI] score) at stipulated time intervals.Results: A total of 812 patients were included - 496 in the pre-ERAS group and 316 in the post-ERAS group. There was no significant difference between the two groups in baseline demographic, clinical, and surgery-related variables. Patients in the post-ERAS group had a significantly shorter LOS (2.94 vs. 3.68 days). The rate of postoperative complications (13.5% vs. 11.7%), 60-day readmission (1.8% vs. 2.2%), and 60-day reoperation (1.2% vs. 1.3%) did not differ significantly between the pre-ERAS and post-ERAS groups. The VAS and ODI scores, similar at baseline, were significantly lower in the post-ERAS group (VAS: 49.8 ± 12.0 vs. 44 ± 10.8, ODI: 31.6 ± 14.2 vs. 28 ± 12.8) at 4 weeks after surgery. This difference however was not significant at intermediate-term follow-up (6 months and 12 months).Conclusion: Implementation of an ERAS protocol is feasible for elective lumbar spine fusion, and leads to shorter LOS and improved early pain and functional outcome scores.Level of Evidence: 3. [ABSTRACT FROM AUTHOR]

Background Data: Povidone-iodine is very effective broad spectrum antiseptic solution against different types of pathogens including methicillin-resistant Staphylococcus aureus and some strains of Enterococcus faecium based on the antiseptic properties of iodine. Purpose: To evaluate the effect of intraoperative 3.35 % povidone-iodine irrigation in lumbar spine fusion surgeries. Study Design: Retrospective clinical case study. Patients and Methods: 93 spine fusion surgeries in 2016 (Group I) and 112 fusion surgeries in 2017 (Group II). Both groups were retrospectively compared regarding infection rate, fusion rate, and Oswestry Disability Index (ODI) score. Group I had intraoperative saline irrigation and Group II was irrigated with 3.35 % povidone-iodine. Results: There were no reported infections in Group II. Two superficial and two deep wound infections were observed in Group I. Complete wound dehiscence was found in one patient with deep wound infection. The pathogens were methicillin-resistant Staphylococcus aureus in two cases, Klebsiella pneumonia in one case, and combination of methicillin-sensitive Staphylococcus aureus and Staphylococcus epidermidis in the last case. There was insignificant difference between the two groups in fusion rates and with no linear correlation relationship between povidone-iodine soaking time and the fusion rate in Group II. There was significant postoperative ODI improvement in the two groups relative to the preoperative scores with insignificant statistical difference when comparing this improvement of the two groups. Conclusion: Povidone-iodine 3.35% irrigation in lumbar spine fusion surgery is effective in decreasing postoperative infection with no negative influence on the fusion rate or clinical outcome. (2019ESJ177)

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

To evaluate the effect of a recent history of total hip arthroplasty (THA) on primary lumbar spine fusion (LSF) for concurrent hip and spine disease. A total of 98,242 patient records from the PearlDiver Database were evaluated and divided into 3 cohorts: 1) patients with a history of LSF alone, 2) patients with a history of LSF for newly diagnosed lumbar disease after having a remote THA> 2 years previously, and 3) patients with a history of LSF after having recent THA <2 years before LSF who initially presented with concurrent hip and lumbar spine disease and underwent THA before LSF. Postoperative outcomes were assessed with multivariable logistic regression to determine the effect of THA on outcomes after LSF with respect to postoperative complications, LSF revision rates, and opioid use. Patients who had LSF after a recent THA had increased risk of deep venous thrombosis (adjusted odds ratio [aOR], 1.39; P = 0.0191), neurologic complications (aOR, 1.81; P = 0.0459), prolonged opioid use (aOR, 1.22; P = 0.0032), and revision LSF (12.8%; P = 0.0004 vs. 9.9%; OR, 1.41; P < 0.0001; hazard ratio, 1.69; P < 0.0001). Patients who underwent LSF after a remote history of THA had no significant difference in DVT (4.2% vs. 2.6%, aOR, 1.31; P = 0.2190), neurologic complications (1.0% vs. 0.5%, aOR, 2.02; P = 0.1220), revision surgery (9.6% vs. 9.9%, aOR, 1.06; P = 0.7197), or prolonged opioid use (36.5% vs. 24.4%, aOR, 1.17; P = 0.1120). Patients who undergo LSF with a history of THA may be at increased risk of postoperative complications, revision LSF, and prolonged opioid use if their THA was performed for concurrent hip-spine disease in the recent past (<2 years). [ABSTRACT FROM AUTHOR]

Abstract Background To analyze the safety and effects of early initiation of rehabilitation including objective measurement outcomes after lumbar spine fusion based on principles of strength training. Methods The study recruited 27 patients, aged 45 to 70 years, who had undergone lumbar spine fusion. The method of concealed random allocation without blocking was used to form two groups. The strength training group started rehabilitation 3 weeks after surgery. Patients exercised twice weekly over 9 weeks focusing on muscle activation of lumbopelvic stabilization muscles. The control group followed a standard postoperative protocol, where no exercises were performed at that stage of rehabilitation. Functional outcomes and plain radiographs were evaluated at 3 weeks and subsequently at 3 and 18 months after the surgery. Results No hardware loosening of failure was observed in the training group. Both groups improved their walking speed after 3 months (p

Study Design: An animal model of anterior lumbar arthrodesis was designed to investigate whether a calcium phosphate cement (CPC) mixed with autologous whole blood might favourably compete with autograft for enhanced spine fusion.Objective: The objective of this study was to use a large animal model to investigate a new approach for spine fusion which consists in the injection of a highly resorbable CPC / blood composite to fill the interbody fusion cage, once placed in the intervertebral space.Summary Of Background Data: Spinal fusion via intervertebral arthrodesis is a common surgical procedure for which the gold standard consists in filling the internal hollow part of the cage with bone autograft. However, this approach suffers from some drawbacks, including a second surgical site which requires additional time spent in the surgical room, and the occurrence of additional new pain on the bone harvesting site along with risks of long-term morbidity.Methods: An animal model of anterior lumbar arthrodesis involved 14 sheep that received a fusion cage in two non-adjacent lumbar levels. For one-half of the animals, the cages were filled after impaction by injection of a CPC/blood composite in one level and the blood-free CPC reference in the other. For the other seven animals, the CPC/blood composite was compared to bone autograft.Results: SEM and histological examination of the explants gave evidence of a good osteointegration for the three types of implanted materials. For the first group, no spine fusion was observed for the blood-free CPC reference while a highly successful spine fusion (6/7 cages) was present for the CPC/blood composite, three months after surgery. For the second group, successful arthrodesis was observed for 57% (4/7) of cages filled with iliac autograft, while the fusion rate was 71% (5/7) in the case of cages filled with the CPC/blood composite.Conclusion: This study reports that the observed fusion rate when filling the cage with a calcium phosphate cement mixed with autologous whole blood was at least as good as results obtained with autograft. Once placed in the intervertebral space, the cage was easily and homogeneously filled with the CPC/blood composite, and this new strategy might thus offer a less invasive option for intervertebral spine fusion.Level Of Evidence: N/A. [ABSTRACT FROM AUTHOR]

Background Context: Understanding the scope of the volume and costs of lumbar fusions and discectomy procedures, as well as identifying significant trends within the Medicare system, may be beneficial in enhancing cost-efficiency and care delivery. However, there is a paucity of studies which analyze recent trends in lumbar fusion volume, utilization, and reimbursements.Purpose: This study seeks to define the costs of lumbar fusions and discectomy procedures and identify trends and variations in volume, utilization, and surgeon and hospital reimbursement rates in the Medicare system between 2012 and 2017.Study Design: Retrospective database study.Patient Sample: Medicare Part A and Part B claims submitted for lumbar spine procedures from 2012 to 2017, as documented in the Centers for Medicare & Medicaid Services Physician and Other Supplier Public Use Files.Outcome Measures: Procedure numbers and payments per episode.Methods: This cross-sectional study tracked annual Medicare claims and payments to spine surgeons using publicly-available databases and aggregated data at the county level. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization rates (per 10,000 Medicare beneficiaries), and reimbursement rates, and to examine associations between county-specific and lumbar spine procedure utilization and reimbursements.Results: A total of 772,532 lumbar spine procedures were performed in the Medicare population from 2012 to 2017, including 634,335 lumbar fusion surgeries and 138,197 primary lumbar discectomy and microdiscectomy single-level surgeries. There was a 26.0% increase in annual lumbar fusion procedure volume during the study period, with a compound annual growth rate (CAGR) of 4.7%. Lumbar discectomy/microdiscectomy experienced a 23.5% decrease in annual procedure volume (CAGR, -5.2%). Mean Medicare surgeon reimbursements for lumbar fusions nominally decreased by 3.7% from $767 in 2012 to $738 in 2017, equivalent to an inflation-adjusted decrease of 11.4% (CAGR, -0.7%). Mean Medicare payments for lumbar discectomy and microdiscectomy procedures nominally increased by 16.3% from $517 in 2012 to $601 in 2017, equivalent to an inflation-adjusted increase of 6.9% (CAGR, 3.1%).Conclusions: This present study found the volume and utilization of lumbar fusions have increased since 2012, while lumbar discectomy and microdiscectomy volume and utilization have fallen. Medicare payments to hospitals and surgeons for lumbar fusions have either declined or not kept pace with inflation, and reimbursements for lumbar discectomy and microdiscectomy to hospitals have risen at a disproportionate rate compared to surgeon payments. These trends in Medicare payments, especially seen in decreasing allocation of reimbursements for surgeons, may be the effect of value-based cost reduction measures, especially for high-cost orthopedic and spine surgeries. [ABSTRACT FROM AUTHOR]

In the present study, we compared the clinical and radiographic outcomes of an interspinous process fixation device (IFD) with those of extended pedicle screw fixation (PSF) for symptomatic adjacent segment disease (ASD) after lumbar fusion. The data from 109 patients with ASD treated with IFD (n = 48) or extended PSF (n = 61) from January 2009 to January 2016 were reviewed retrospectively. The clinical outcomes were measured using a visual analog scale (VAS) and the Oswestry disability index. The radiographic outcomes included the fusion rate, incidence of cage subsidence, and additional radiographic ASD. The mean incision length, operative time, blood loss, and length of hospital stay were significantly lower in the IFD group (P < 0.001). Postoperative back and leg pain were relieved in both groups (P < 0.001). The mean preoperative VAS scores were 8.3 ± 1.3 and 8.5 ± 1.1 in the IFD and PSF groups and had improved to 2.8 ± 1.1 and 2.7 ± 1.2 after 36 months, respectively (P < 0.001). At 36 months postoperatively, 10 of the 56 patients (17.9%) in the PSF group had developed additional radiographic ASD compared with 2 of 44 patients (4.5%) in the IFD group. Our results have demonstrated that in the treatment of symptomatic ASD, comparable clinical and radiologic outcomes can be achieved using IFD, which has a shorter skin incision, shorter operative time, less intraoperative blood loss, and shorter hospital stay than the extended PSF technique. Although not statistically significant, the IFD resulted in a lower ASD incidence compare with the PSF technique. Thus, IFD might be an alternative surgical method for symptomatic ASD after lumbar spine fusion. [ABSTRACT FROM AUTHOR]

Abstract Background Both the map3 Cellular Allogeneic Bone Graft® and recombinant human bone morphogenetic protein 2 (rhBMP-2, Infuse®) were developed to provide an alternative to iliac crest autograft, thus eliminating the morbidity associated with its harvest. The recent literature concerning adverse events associated with the use of rhBMP-2, however, highlights the need for a safe and effective alternative. The multipotent adult progenitor cells (MAPC) found in map3 allograft may provide this alternative. The purpose of this study is to report 1-year outcomes of patients treated via anterior lumbar interbody fusion (ALIF) using either map3 Cellular Allogeneic Bone Graft or rhBMP-2 for bony fusion. Methods This was a retrospective evaluation of 41 patients treated via ALIF with either map3 or rhBMP-2 in a polyetheretherketone cage with posterior stabilization at 1, 2, or 3 consecutive levels (L3-S1). Patients were equally divided between treatment groups. The Oswestry Disability Index (ODI) and visual analog scores (VAS) for pain were documented as part of the standard of care. An independent radiologist assessed bridging of bone, disc height, and lordosis. Primary outcome measures included radiographic analysis of fusion by plain film and CTs. Secondary clinical outcomes included visual analogue scale for neck and arm pain and low back disability index scores. Results The overall fusion rate was 91%, with no significant difference between groups. Improvements in ODI and VAS were observed among all patients (p

Purpose: To develop a model to predict 30-day readmission rates in elective 1-2 level posterior lumbar spine fusion (PSF) patients.Methods: In this retrospective case control study, patients were identified in the State Inpatient Database using ICD-9 codes. Data were queried for 30-day readmission, as well as demographic and surgical data. Patients were randomly assigned to either the derivation or the validation cohort. Stepwise multivariate analysis was conducted on the derivation cohort to predict 30-day readmission. Readmission after posterior spinal fusion (RAPSF) score was created by including variables with odds ratio (OR) > 1.1 and p < 0.01; value assigned to each variable was based on the OR and calibrated to 100. Linear regression was performed between readmission rate and RAPSF score to test correlation in both cohorts.Results: There were 92,262 and 90,257 patients in the derivation and validation cohorts. Thirty-day readmission rates were 10.9% and 11.1%, respectively. Variables in RAPSF included: age, female gender, race, insurance, anterior approach, cerebrovascular disease, chronic pulmonary disease, congestive heart failure, diabetes, hemiplegia/paraplegia, rheumatic disease, drug abuse, electrolyte disorder, osteoporosis, depression, obesity, and morbid obesity. Linear regression between readmission rate and RAPSF fits the derivation cohort and validation cohort with an adjusted r2 of 0.92 and 0.94, respectively, and a coefficient of 0.011 (p < 0.001) in both cohorts.Conclusion: The RAPSF can accurately predict readmission rates in PSF patients and may be used to guide an evidence-based approach to preoperative optimization and risk adjustment within alternative payment models for elective spine surgery.Level Of Evidence: 3. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective study using prospectively collected registry data.Objectives: To evaluate the effect of obesity on patient-reported outcome measures of pain, disability, quality of life, satisfaction, and return to work after single-level minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF).Summary Of Background Data: MIS-TLIF is an appealing alternative for obese patients with potentially lower complication risk. However, there is limited data investigating the influence of obesity on outcomes 5 years after MIS-TLIF.Methods: Prospectively collected registry data of 296 patients who underwent single-level MIS-TLIF at a single institution were reviewed. Patients had complete 2- and 5-year follow-up data. Patients were stratified into control (<25.0 kg/m), overweight (25.0-29.9 kg/m), and obese (≥30.0 kg/m) groups. Outcomes assessed were visual analogue scale for back pain, leg pain, Oswestry Disability Index, Short-form 36, North American Spine Society score for neurogenic symptoms, return to work (RTW), return to function (RTF), satisfaction, and expectation fulfilment. Length of operation, length of stay, and comorbidities were recorded.Results: Among the patients, 156 (52.7%) had normal weight, 108 (36.5%) were overweight, and 32 (10.8%) were obese. There was no difference in length of operation or hospitalization (P > 0.05). All three groups had comparable preoperative scores at baseline (P > 0.05). At 5 years, the control group had significantly higher PCS compared with the overweight (P = 0.043) and obese groups (P = 0.007), although the change in scores was similar (P > 0.05). The rate of MCID attainment, RTW, RTF, expectation fulfilment, and satisfaction was comparable.Conclusion: Nonobese patients had better physical well-being in the mid-term, although obese patients experienced a comparable improvement in clinical scores. Obesity had no impact on patients' ability to RTW or RTF. Equivalent proportions of patients were satisfied and had their expectations fulfilled up to 5 years after MIS-TLIF.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

Background: Approximately one-third of patients undergoing spine surgery have symptoms of anxiety and depression that correlate with pain, disability, and lower health-related quality of life. The use of web-based informative strategies before surgery and principles from cognitive behavioral therapy, have been applied in other patient groups, facilitating mobility and encouraging beneficial coping behavior.Purpose: To examine the effect of a web-based Spine Platform featuring Interaction and Information by Animation (w-SPIINA) on symptoms of anxiety and depression, pain, disability, and health-related quality of life.Study Design: A single-center, two-arm, randomized controlled trial PATIENT SAMPLE: One hundred fourteen consecutive patients scheduled for instrumented lumbar spine fusion due to degenerative disc disease or spondylolisthesis.Outcome Measures: Primary outcome was the change in self-reported Hospital Anxiety and Depression Scale (HADS) scores from baseline to 3-month follow-up. Secondary outcomes were change in HADS 1-day before surgery 2days and 6 months after and changes in self-reported disability measured on the Oswestry disability index (ODI), quality of life (EQ-5D-5L questionnaire), and the low back pain rating scale (LBPRS) 2days and 3 and 6 months after surgery.Method: Patients were randomized to either a control group receiving a standard information regimen or an intervention group gaining access to w-SPIINA in addition to the standard regimen. The independent charity Helsefonden contributed $45,000, the Health Research Fund of the Regional Hospital Central Jutland contributed $10,000, and the Toyota foundation contributed $10,000 to remunerate a dedicated investigator. The authors have no conflict of interest to declare.Results: There was no statistically significant difference within the w-SPIINA group and the control group regarding changes in HADS at 3-month follow-up (p≥.37). Approximately 40% reached minimum clinically important difference (MCID) in the w-SPIINA group on the HADS at 3 months. In the control group 50% reached MCID on anxiety subscale and 35% on the depression subscale at 3 months. No statistically significant differences were found between groups with regard to the overall outcomes at any of the predefined time points.Conclusion: Providing patients with access to w-SPIINA in addition to a standard information regimen had no additional effect on HADS and patient-reported outcomes1day before, 2days, 3 or 6 months after surgery. However, a high compliance and degree of interaction with w-SPIINA indicates that this mode of web-based support could be applicable in this group of patients. [ABSTRACT FROM AUTHOR]

Background: Patients undergoing primary total hip arthroplasty (THA) following lumbar spine fusion have an increased incidence of dislocation compared to those without prior lumbar fusion. The purpose of this study is to determine if timing of THA prior to or after lumbar fusion would have an effect on dislocation and revision incidence in patients with both hip and lumbar spine pathology.Methods: One hundred percent Medicare inpatient claims data from 2005 to 2015 were used to compare dislocation and revision risks in patients with primary THA with pre-existing lumbar spine fusion vs THA with subsequent lumbar spine fusion within 1, 2, and 5 years after the index THA. A total of 42,300 patients met inclusion criteria, 28,668 patients of which underwent THA with pre-existing lumbar spinal fusion (LSF) and 13,632 patients who had prior THA and subsequent LSF. Patients who had THA first followed by LSF were further stratified based on the interval between index THA and subsequent LSF (1, 2, and 5 years), making 4 total groups for comparison. Multivariate cox regression analysis was performed adjusting for age, socioeconomic status, race, census region, gender, Charlson score, pre-existing conditions, discharge status, length of stay, and hospital characteristics.Results: Patients with prior LSF undergoing THA had a 106% increased risk of dislocation compared to those with LSF done 5 years after THA (P < .001). Risk of revision THA was greater in the pre-existing LSF group by 43%, 41%, and 49% at 1, 2, and 5 years post THA compared to the groups with THA done first with subsequent LSF. Dislocation was the most common etiology for revision THA in all groups, but significantly higher in the prior LSF group (26.6%).Conclusion: Results of this study demonstrate that sequence of surgical intervention for concomitant lumbar and hip pathology requiring LSF and THA respectively significantly impacts the fate of the THA performed. Patients with prior LSF undergoing THA are at significantly higher risk of dislocation and subsequent revision compared to those with THA first followed by delayed LSF.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective analysis of Medicare claims and procedure details from a single institution participation in the Bundled Payments for Care Improvement (BPCI) program.Objective: To analyze the effects of the BPCI program on patient outcome metrics and cost data.Summary Of Background Data: The BPCI program was designed to improve the value of care provided to patients, but the financial consequences of this system remain largely unknown. We present 2 years of data from participation in the lumbar spine fusion bundle at a large, urban, academic institution.Methods: In 2013 and 2014, all Medicare patients undergoing lumbar spine fusions for DGR 459 (spinal fusion except cervical with major complication or comorbidity [MCC]) and 460 (without MCC) at our institution were enrolled in the BPCI program. We compared the BPCI cohort to a baseline cohort of patients under the same diagnosis related groups (DRGs) from 2009 to 2012 from which the target price was established.Results: Three hundred fifty patients were enrolled into the BPCI program, while the baseline group contained 518 patients. When compared with the baseline cohort, length of stay decreased (4.58 ± 2.51 vs. 5.13 ± 3.75; P = 0.009), readmission rate was unchanged, and discharges with home health aid increased. Nonetheless, we were unable to effect an episode-based cost savings ($52,655 ± 27,028 vs. $48,913 ± 24,764). In the larger DRG 460 group, total payments increased in the BPCI group ($51,105 ± 26,347 vs. $45,934 ± 19,638, P = 0.001). Operative data demonstrated a more complex patient mix in the BPCI cohort. The use of interbody fusions increased from 2% to 16% (P < 0.001), and the percentage of complex spines increased from 23% to 45% (P < 0.001).Conclusion: Increased case complexity was responsible for increasing costs relative to the negotiated baseline target price. This payment system may discourage advancement in spine surgery due to the financial penalty associated with novel techniques and technologies.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

Study Design: Observational study.Objective: To evaluate how online patient comments will affect website ratings for spine surgeons.Summary Of Background Data: With the ever-growing utilization of physician review websites, healthcare consumers are assuming more control over whom they choose for care. We evaluated patient feedback and satisfaction scores of spine surgeons using comments from three leading physician rating websites: Healthgrades.com, Vitals.com, Google.com. This is the largest review of online comments and the largest review of spine surgeon comments.Methods: From the North American Spine Society (NASS) membership directory, 210 spine surgeons practicing in Florida (133 orthopedic trained; 77 neurosurgery trained) with online comments available for review were identified, yielding 4701 patient comments. These were categorized according to subject: (1) surgeon competence, (2) surgeon likeability/character, (3) office staff, ease of scheduling, office environment. Type 1 and 2 comments were surgeon-dependent factors whereas type 3 comments were surgeon-independent factors. Patient comments also reported a score (1-5), 5 being the most favorable and 1 being the least favorable.Results: There were 1214 (25.8%) comments from Healthgrades, 2839 (60.4%) from Vitals, and 648 (13.8%) from Google. 89.9% (4225) of comments pertained to surgeon outcomes and likeability (comment type 1 and 2), compared with 10.1% (476) surgeon-independent comments (comment type 3) (P < 0.0001). There was a significantly higher number of favorable ratings associated with surgeon-dependent comments (types 1 and 2) compared with surgeon-independent comments (type 3). Surgeon-independent comments were associated with significantly lower scores compared with comments regarding surgeon-dependent factors on all review sites.Conclusion: Spine surgeons are more likely to receive favorable reviews for factors pertaining to outcomes, likeability/character, and negative reviews based on ancillary staff interactions, billing, and office environment. Surgeons should continue to take an active role in modifying factors patients perceive as negative, even if not directly related to the physician.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

Background: In patients with concomitant hip and lumbar spine disease, the question of which surgery-total hip arthroplasty (THA) or lumbar spine fusion (LSF)-to address first has not been adequately answered. We aimed to evaluate the risk of dislocation after THA in patients with LSF first or after THA., Methods: Retrospective review utilizing the PearlDiver database querying Current Procedural Terminology codes for LSF in the year prior (LSF first) or in the year after primary or revision THA (THA first). International Classification of Disease codes identified postoperative hip dislocation as our primary outcome variable. Demographic data collected included age, sex, and obesity. Dislocation rates were described as a proportion of the cohort and compared with chi-square tests., Results: We identified 280,857 primary THA and 42,314 revision THA cases from 2012-2019. Of these, 2090 underwent primary THA and LSF, and 283 underwent revision THA and LSF within a year of each procedure. No differences in age, sex, or obesity between groups were noted. No difference in rate of all-time dislocation for primary THA was noted for the LSF first 51/1429 (3.6%) compared to the THA first 30/661 (4.0%) groups ( P  = .34), or for revision THA with LSF first 48/204 (23.5%) compared to THA first 27/117 (23.1%) groups ( P  = 1.0)., Conclusions: There was no difference in the risk of dislocation after primary or revision THA if LSF occurred prior to or after the THA. These findings can help surgeons as they counsel patients with concomitant lumbar spine and hip degeneration., (© 2023 The Authors.)

Background Context: Lumbar spine fusion (LSF) surgery is a viable form of treatment for several spinal disorders. Treatment effects are preferably to be endorsed in real-life settings., Methods: This prospective study evaluated the 10-year outcomes of LSF. A population-based series of elective LSFs performed at 2 spine centers between January 2008 and June 2012 were enrolled. Surgeries for tumor, acute fracture, or infection, neuromuscular scoliosis, or postoperative conditions were excluded. The following patient-reported outcome measures (PROMs) were collected at baseline, and 1, 2, 5, and 10 years postsurgery: VAS for back and leg pain, ODI, SF-36. Longitudinal measures of PROMs were analyzed using mixed-effects models., Results: A total of 683 patients met the inclusion criteria, and 630 (92%) of them completed baseline and at least 1 follow-up PROMs, and they constituted the study population. Mean age was 61 (SD 12) years, 69% women. According to surgical indication, patients were stratified into degenerative spondylolisthesis (DS, n=332, 53%), spinal stenosis (SS, n=102, 16%), isthmic spondylolisthesis (IS, n=97, 15%), degenerative disc disease (DDD, n=52, 8%), and deformity (DF, n=47, 7%).All diagnostic cohorts demonstrated significant improvement at 1 year, followed by a partial loss of benefits by 10 years. ODI baselines and changes at 1 and 10 years were: (DS) 45, -21, and -14; (SS) 51, -24, and -13; (IS) 41, -24, and -20; (DDD) 50, -20, and -20; and (DF) 50, -21, and -16, respectively. Comparable patterns were seen in pain scores. Significant HRQoL achievements were recorded in all cohorts, greatest in physical domains, but also substantial in mental aspects of HRQoL., Conclusions: Benefits of LSF were partially lost but still meaningful at 10 years of surgery. Long-term benefits seemed milder with degenerative conditions, reflecting the progress of the ongoing spinal degeneration. Benefits were most overt in pain and physical function measures., Competing Interests: One or more of the authors declare financial or professional relationships on ICMJE-NASSJ disclosure forms., (© 2023 The Author(s).)

Background: The purpose of this study was to determine whether the risk of dislocation and/or revision following THA is increased in patients with a history of prior lumbar fusion given the alterations in dynamic pelvic motion following LSF.Methods: A total of 62,387 patients (5% Medicare part B claims database) were identified from 1997 to 2014 with primary THA. From this group, 1809 patients (2.9%) were stratified to identify those with prior lumbar fusion within 5 years of primary THA to compare risk of dislocation and revision with those without lumbar fusion. Multivariate cox regression analysis was performed adjusting for age, socioeconomic status, race, census, region, gender, Charlson score, preexisting conditions, and type of fusion.Results: Between years 2002 and 2014, there was a 293% increase in the number of patients with prior lumbar fusion undergoing THA. Prevalence of hip dislocation in patients with lumbar fusion before THA was 7.4% compared to 4.8% without fusion, P < .001. There was an 80% increase in dislocation in the fusion group at 6 months, 71% at 1 year, and 60% at 2 years. There was a 48% increased risk of failure leading to revision hip surgery in patients with fusion at 6 months, 41% at 1 year, and 47% at 2 years. Dislocation was the most common mode of failure leading to revision in both the fusion group (20.8%) and the nonfusion group (16%).Conclusion: Results of this study demonstrate that lumbar fusion before THA is an independent risk factor for dislocation leading to increased risk of revision THA. [ABSTRACT FROM AUTHOR]

Background: Both the map3 Cellular Allogeneic Bone Graft® and recombinant human bone morphogenetic protein 2 (rhBMP-2, Infuse®) were developed to provide an alternative to iliac crest autograft, thus eliminating the morbidity associated with its harvest. The recent literature concerning adverse events associated with the use of rhBMP-2, however, highlights the need for a safe and effective alternative. The multipotent adult progenitor cells (MAPC) found in map3 allograft may provide this alternative. The purpose of this study is to report 1-year outcomes of patients treated via anterior lumbar interbody fusion (ALIF) using either map3 Cellular Allogeneic Bone Graft or rhBMP-2 for bony fusion. Methods: This was a retrospective evaluation of 41 patients treated via ALIF with either map3 or rhBMP-2 in a polyetheretherketone cage with posterior stabilization at 1, 2, or 3 consecutive levels (L3-S1). Patients were equally divided between treatment groups. The Oswestry Disability Index (ODI) and visual analog scores (VAS) for pain were documented as part of the standard of care. An independent radiologist assessed bridging of bone, disc height, and lordosis. Primary outcome measures included radiographic analysis of fusion by plain film and CTs. Secondary clinical outcomes included visual analogue scale for neck and arm pain and low back disability index scores. Results: The overall fusion rate was 91%, with no significant difference between groups. Improvements in ODI and VAS were observed among all patients (p < 0.001), with no significant difference between groups for ODI (p = 0.966) or VAS (p = 0.251). There was no significant difference in terms of changes to disc height and lordosis between groups (p < 0.05). The rhBMP-2 group had increased post-operative complications when compared to the map3 group, but the low numbers precluded statistical analysis. Conclusion: Improvements in radiographic and clinical findings were observed in both treatment groups one-year postoperatively. Map3 allograft demonstrated equivalent fusion rates to rhBMP-2. A review of surgical supply costs at the treatment facility favored map3 allograft for the treatment of patients with DDD undergoing an ALIF in 1-3 levels compared to rhBMP-2. Further studies to evaluate long-term outcomes and post-operative complications are required. [ABSTRACT FROM AUTHOR]

Background Context: Spinal fusion procedures are intended to stabilize the spinal column for a multitude of disorders including abnormal curvature, traumatic instability, degenerative instability, and damage from infections or tumors. As an aid in the bone healing response, bone graft materials are used to bridge joints for arthrodesis and promote unions in pseudoarthrosis. Currently, the gold standard for stabilizing fusion masses in spinal procedures involves using the osteogenic, osteoinductive, and osteoconductive properties of autologous iliac crest corticocancellous bone. However, considerable morbidity is associated with harvesting the autologous graft. Donor site complications including infection, large hematomas, and pain have been reported at rates as high as 50% (Boden and Jeffrey, 1995). Biologically, the rate of bone repair dictates the rate at which the fusion mass will unite under autologous graft conditions.Purpose: The purpose of this study is to compare the quality and rate of fusion between Accell Evo3 and Grafton demineralized bone matrix (DBM), with the gold standard iliac crest bone graft (ICBG) as the control, in athymic rat posterolateral fusion.Study Design: This study was a randomized, controlled study in a laboratory setting at the Hospital for Special Surgery in New York City. Blinded observations were made, which created an assessment of outcomes for successful fusions between each method.Patient Sample: Forty-eight (48) athymic rats were used in this study and underwent posterolateral lumbar fusion. They were assessed at either 3 weeks or 9 weeks to see the rate and efficacy of fusion.Outcome Measures: Outcome measures will be the efficacy of the different bone grafts and their success rates of fusion in the rats.Methods: A comparison of the quality and rate of fusion between Accell Evo3® (DBM A) and Grafton (DBM B), with the gold standard iliac crest bone graft (ICBG) as the control, was performed using the established posterolateral intertransverse process on an athymic rat model. Materials were evaluated for fusion by several criteria, including manual palpation, standard and high-resolution radiographic imaging, micro-computed topography, and histologic analysis. Forty-eight (48) athymic rats received a bilateral intertransverse process fusion, using either bone from the iliac crest (control group), Accell Evo3, or Grafton. Twelve (12) rats (four from each group) were sacrificed at 3 weeks postoperatively, whereas the remaining thirty-six (36) were sacrificed at 9 weeks postoperatively. Three blinded observers examined the spines after the rats were euthanized, and they blindly assessed each rat for fusion success.Results: Manual palpation of the three different groups at 3 weeks postoperatively found successful fusion in 1 of 4 (25%) of the autologous bone graft (ABG) group and 4 of 4 (100%) of both DBM A and B groups. Manual palpation of the remaining animals that were sacrificed at 9 weeks postoperatively showed successful fusion in 4 of 12 (33%) of the ABG group, 8 of 12 (66%) of the DBM A group, and 12 of 12 (100%) of the DBM B group. Radiography found that 9 of 16 (56%) of the ABG group and 16 of 16 (100%) of both DBM Putty A and B groups had fused. Histologic analysis of the ABG group demonstrated less mature and less organized osteoid at both 3 and 9 weeks than the DBM Putty A and B groups. Nondestructive mechanical testing demonstrated increased stiffness in 4-point bending of both DBM A and B compared with ABG.Conclusions: Both DBM-treated groups achieved a significantly higher rate of fusion than the ABG-treated group at 9 weeks in this model. Successful fusion was also demonstrated in the DBM-treated groups at 3 weeks. [ABSTRACT FROM AUTHOR]

Background: Spine surgery has been transformed significantly by the growth of minimally invasive surgery (MIS) procedures. Easily marketable to patients as less invasive with smaller incisions, MIS is often perceived as superior to traditional open spine surgery. The highest quality evidence comparing MIS with open spine surgery was examined. Methods: A systematic review of randomized controlled trials (RCTs) involving MIS versus open spine surgery was performed using the Entrez gateway of the PubMed database for articles published in English up to December 28, 2015. RCTs and systematic reviews of RCTs of MIS versus open spine surgery were evaluated for three particular entities: Cervical disc herniation, lumbar disc herniation, and posterior lumbar fusion. Results: A total of 17 RCTs were identified, along with six systematic reviews. For cervical disc herniation, MIS provided no difference in overall function, arm pain relief, or long-term neck pain. In lumbar disc herniation, MIS was inferior in providing leg/low back pain relief, rehospitalization rates, quality of life improvement, and exposed the surgeon to >10 times more radiation in return for shorter hospital stay and less surgical site infection. In posterior lumbar fusion, MIS transforaminal lumbar interbody fusion (TLIF) had significantly reduced 2-year societal cost, fewer medical complications, reduced time to return to work, and improved short-term Oswestry Disability Index scores at the cost of higher revision rates, higher readmission rates, and more than twice the amount of intraoperative fluoroscopy. Conclusion: The highest levels of evidence do not support MIS over open surgery for cervical or lumbar disc herniation. However, MIS TLIF demonstrates advantages along with higher revision/readmission rates. Regardless of patient indication, MIS exposes the surgeon to significantly more radiation; it is unclear how this impacts patients. These results should optimize informed decision-making regarding MIS versus open spine surgery, particularly in the current advertising climate greatly favoring MIS. [ABSTRACT FROM AUTHOR]

Purpose: The aim of the study was to investigate the effectiveness of the postoperative 12-month exercise program compared to usual care on disability and health-related quality of life (HRQoL) in patients after lumbar spine fusion surgery (LSF).Methods: Altogether, 98 patients with isthmic (31) or degenerative (67) spondylolisthesis were randomised to exercise therapy group (EG) (n = 48) or usual care group (UCG) (n = 50) 3 months after LSF. EG patients had home-based progressive strength and aerobic training program for 12 months. UCG patients received only oral and written instructions of exercises. Oswestry Disability Index (ODI) and HRQoL (RAND-36) were evaluated at the time of randomization, at the end of the intervention and 1 year after intervention.Results: The mean ODI score decreased from 24 (12) to 18 (14) in the EG and from 18 (12) to 13 (11) in the UCG during intervention (between-groups p = 0.69). At 1-year follow-up, 25 % of the EG and 28 % of the UCG had an ODI score ≥20. No between-group differences in HRQoL change were found at any time point. The mean (95 % CI) physical functioning dimension of the HRQoL improved by 10.0 (4.6-15.3) in the EG and by 7.8 (2.5-13.0) in the UCG. In addition, the role physical score improved by 20.0 (7.7-32.3) in the EG and by 16.4 (4.4-28.4) in the UCG during the intervention.Conclusions: The exercise intervention did not have an impact on disability or HRQoL beyond the improvement achieved by usual care. However, disability remained at least moderate in considerable proportion of patients. [ABSTRACT FROM AUTHOR]

Background: Patients who have prior lumbar spine fusion (LSF) have an increased risk for dislocation after total hip arthroplasty (THA). These patients also have elevated rates of opioid use. We aimed to evaluate the associated risk of dislocation after THA in patients who have prior LSF comparing those who have opioid use to those who do not., Methods: This was a retrospective review using a large national database of 246,617 primary and 34,083 revision THA cases from 2012 to 2019. There were 1,903 primary THA and 288 revision THA cases identified with LSF prior to THA. Postoperative hip dislocation was our primary outcome variable and patients were stratified to use or nonuse of opioid at THA. Demographic data including age, sex, and obesity were collected. Multivariate analyses evaluated association of opioid use and dislocation after adjusting for demographics., Results: There was increased odds of dislocation for opioid use at THA for both primary (adjusted Odds Ratio [aOR] = 2.29, 95% Confidence Interval [CI] 1.46 to 3.57, P < .0003) and revision THA (aOR = 1.92, 95% CI 1.62 to 3.08, P < .0003), in patients who have prior LSF. Prior LSF without opioid use was associated with increased odds of dislocation (aOR = 1.38, 95% CI 1.01 to 1.88, P = .04), but this was lower than the associated risk of opioid use without LSF (aOR 1.72, 95% CI 1.63 to 1.81, P < .001)., Conclusion: Increased odds of dislocation were noted with opioid use at time of THA in patients who have prior LSF. Associated risk of dislocation was higher for opioid use than prior LSF. This suggests that dislocation risk is multifactorial and we should look to strategies to reduce opioid use prior to THA., (Copyright © 2023 Elsevier Inc. All rights reserved.)