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Myocardial infarction (MI), and its predictive factors, has been an understudied complication following spine operations. The objective was to assess the risk factors for perioperative MI in elective spine surgery patients as a retrospective case control study. Elective spine surgery patients with a perioperative MI were isolated in the NSQIP. The relationship between MI and non-MI spine patients was assessed using chi-squared and independent samples t-tests. Univariate/multivariate analyses assessed predictive factors of MI. Logistic regression with stepwise model selection was employed to create a model to predict MI occurrence. The study included 196,523 elective spine surgery patients (57.1 yrs, 48%F, 30.4 kg/m

BACKGROUND: Patients undergoing surgical treatment of adult spinal deformity (ASD) are often preoperatively risk stratified using standardized instruments to assess for perioperative complications. Many ASD instruments account for medical comorbidity and radiographic parameters, but few consider a patient’s ability to independently accomplish necessary activities of daily living (ADLs). METHODS: Patients ≥18 years undergoing ASD corrective surgery were identified in National Surgical Quality Improvement Program. Patients were grouped by (1) plegic status and (2) dependence in completing ADLs (“totally dependent” = requires total assistance in ADLs, “partially dependent” = uses prosthetics/devices but still requires help, “independent” = requires no help). Quadriplegics and totally dependent patients comprised “severe functional dependence,” paraplegics/hemiplegics who are “partially dependent” comprised “moderate functional dependence,” and “independent” nonplegics comprised “independent.” Analysis of variance with post hoc testing and Kruskal-Wallis tests compared demographics and perioperative outcomes across groups. Logistic regression found predictors of inferior outcomes, controlling for age, sex, body mass index (BMI), and invasiveness. Subanalysis correlated functional dependence with other established metrics such as the modified Frailty Index (mFI) and Charlson Comorbidity Index (CCI). RESULTS: A total of 40,990 ASD patients (mean age 57.1 years, 53% women, mean BMI 29.8 kg/m(2)) were included. Mean invasiveness score was 6.9 ± 4.0; 95.2% were independent (Indep), 4.3% moderate (Mod), and 0.5% severe (Sev). Sev had higher baseline invasiveness than Mod or Indep groups (9.0, 8.3, and 6.8, respectively, P < 0.001). Compared with the Indep patients, Sev and Mod had significantly longer inpatient length of stay (LOS; 10.9, 8.4, 3.8 days, P < 0.001), higher rates of surgical site infection (2.2%, 2.9%, 1.5%, P < 0.001), and more never events (17.7%, 9.9%, 4.0%, P < 0.001). Mod had higher readmission rates than either the Sev or Indep groups (30.2%, 2.7%, 10.3%, P < 0.001). No differences in implant failure were observed (P > 0.05). Controlling for age, sex, BMI, CCI, invasiveness, and frailty, regression equations showed increasing functional dependence significantly increased odds of never events (OR, 1.82 [95% CI 1.57–2.10], P < 0.001), specifically urinary tract infection (OR, 2.03 [95% CI 1.66–2.50], P < 0.001) and deep venous thrombosis (OR, 2.04 [95% CI 1.61–2.57], P < 0.001). Increasing functional dependence also predicted longer LOS (OR, 3.16 [95% CI 2.85–3.46], P < 0.001) and readmission (OR, 2.73 [95% CI 2.47–3.02], P < 0.001). Subanalysis showed functional dependence correlated more strongly with mFI (r = 0.270, P < 0.001) than modified CCI (mCCI; r = 0.108, P < 0.001), while mFI and mCCI correlated most with one another (r = 0.346, P < 0.001). CONCLUSIONS: Severe functional dependence had significantly longer LOS and more never-event complications than moderate or independent groups. Overall, functional dependence may show superiority to traditional metrics in predicting poor perioperative outcomes, such as increased LOS, readmission rate, and risk of surgical site infection and never events. LEVEL OF EVIDENCE: 3.

BACKGROUND: Spinal surgery is associated with an inherently elevated risk profile, and thus far there has been limited discussion about how these outpatient spine patients are benefiting from these same-day procedures against other typical outpatient orthopedic surgeries. METHODS: Orthopedic patients who received either inpatient or outpatient surgery were isolated in the American College of Surgeons National Surgical Quality of Improvement Program (2005–2016). Patients were stratified by type of orthopedic surgery received (spine, knee, ankle, shoulder, or hip). Mean comparisons and chi-squared tests assessed basic demographics. Perioperative complications were analyzed via regression analyses in regard to their principal inpatient or outpatient orthopedic surgery received. RESULTS: This study included 729 480 surgical patients: 32.5% received spinal surgery, 36.5% knee, 24.1% hip, 4.9% shoulder, and 1.7%ankle. Of those who received a spinal procedure, 74.7% were inpatients (IN), and 25.3% were outpatients (OUT): knee: 96.1% IN, 3.9% OUT; hip:98.9% IN, 1.1% OUT; ankle: 29% IN, 71% OUT; and shoulder: 52.6% IN, 47.6% OUT. Hip patients were the oldest, and knee patients had the highest body mass index out of the orthopedic groups (P < .00). Spine IN patients experienced more complications than the other orthopedic groups and had the lowest OUT complications(both P < .05). This same trend of having higher IN complications than OUT complications was identified for hip, shoulder, and knee. However, ankle procedures had greater OUT procedure complications than IN (P < .05). After controlling for age, body mass index, and Charlson Comorbidity Index, IN procedures, such as knee, hip, spine, and shoulder, were significantly associated with experiencing postoperative complications. From 2006 to 2016, IN and OUT surgeries were significantly different among complications experienced for all of the orthopedic groups (P < .05) with complications decreasing for IN and OUT patients by 2016. CONCLUSIONS: Over the past decade, spine surgery has decreased in complications for IN and OUT procedures along with IN/OUT knee, ankle, hip, and shoulder procedures, reflecting greater tolerance for risk in an outpatient setting. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: Despite the increase in riskier spine procedures, complications have decreased over the years. Surgeons should aim to continue to decrease inpatient spine complications to the level of other orthopedic surgeries.

Multidisciplinary patient-reported outcomes are a critical part of assessing patients to better understand their well-being during treatment. The use of multidisciplinary patient-reported outcomes is recommended in many areas of medicine. The Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29) has been utilized as a common measurement language across universally relevant domains, including pain, mood, sleep, social participation, and function. Retrospective analysis of prospectively collected data was performed. Subjects were identified and consecutively enrolled upon entry into chronic pain centers across 24 sites in the United States. The PROMIS-29 v2.1 and the numerical rating scale (NRS) were recorded. The pain impact score and the Health Utilities Index Mark 3 (HUI-3) were calculated. Statistical differences were assessed between genders and among age groups comprising subjects less than 40, 41–60, 61–80, and over 80 years of age. A total of 19,546 patients were assessed over the enrollment period from 2018 to 2020. The PROMIS-29 v2.1 was evaluated across the seven domains, along with the numerical rating sale (NRS). The mean scores of the population for PROMIS SF v1.0 Pain Interference 4a, PROMIS SF v1.0 Sleep Disturbance 4a, PROMIS SF v1.0 Fatigue 4a, PROMIS SF v1.0 Anxiety 4a, PROMIS SF V1.0 Depression 4a, PROMIS SF v2.0 Ability to Participate in Social Roles and Activities 4a, and PROMIS SF v1.0 Physical Function 4a, measuring pain interference, sleep disturbance, fatigue, anxiety, depression, social participation, and physical function, were 64.61, 57.19, 58.50, 53.94, 54.45, 40.06, and 36.23, respectively. Pain intensity was 6.38 on an 11-point NRS scale. The pain impact score (PIS) and health utilities index mark 3 (HUI-3) scores, calculated across the designated age groups, were 33.19 and 0.67, respectively. Statistical differences were observed for the domains of sleep disturbance and physical function for age groups less than 40 and greater than 80 years of age. This data set is the first published normative data set describing the PROMIS-29 assessment in the chronic pain population. The patient population is more homogeneous than expected, and females were found to have higher levels of dysfunction.

Psychiatric diagnoses (PD) present a significant burden on elective surgery patients and may have potentially dramatic impacts on outcomes. As ailments of the spine can be particularly debilitating, the effect of PD on outcomes was compared between elective spine surgery patients and other common elective orthopedic surgery procedures. This study included 412,777 elective orthopedic patients who were concurrently diagnosed with PD within the years 2005 to 2016. 30.2% of PD patients experienced a post-operative complication, compared to 25.1% for non-PD patients (p 0.001). Mood Disorders (bipolar or depressive disorders) were the most commonly diagnosed PD for all elective Orthopedic procedures, followed by anxiety, then dementia (p 0.001). Logistic regression analysis found PD to be a significant predictor of higher cost to charge ratio (CCR), length of stay (LOS), and death (all p 0.001). Between, hand, elbow, and shoulder specialties, spine patients had the highest odds of increased CCR and unfavorable discharge, and the second highest odds of death (all p 0.001).

BACKGROUND CONTEXT Numerous advances have been made in the field of spine fusion, such as minimally invasive (MIS) or robotic-assisted spine surgery. However, it is unknown how these advances have impacted the cost of care. PURPOSE Compare the economic outcomes of lumbar spine fusion between open, MIS, and robot-assisted surgery patients. STUDY DESIGN/SETTING Retrospective review of a single center spine surgery database. PATIENT SAMPLE Three hundred sixty propensity matched patients. OUTCOME MEASURES Costs, EuroQol-5D (EQ5D), cost per quality adjusted life years (QALY). METHODS Inclusion criteria: surgical patients >18 years undergoing lumbar fusion surgery. Patients were categorized into 3 groups based on procedure type: open, MIS, or robotic. Open patients undergoing poster spinal fusion were considered as the control group. MIS patients included those undergoing transforaminal or lateral lumbar interbody fusion with percutaneous screws. Robotic patients were those undergoing robot-assisted fusion. Propensity score matching was performed between all groups for the number of levels fused. Costs were calculated using the PearlDiver database, which reflects both private insurance and Medicare reimbursement claims for ICD-9 codes. For robotic cases, costs were reflective of operational fees and initial purchase cost. Complications and comorbidities and major complications and comorbidities were assessed according to CMS.gov manual definitions. QALYs and cost per QALY were calculated using a 3% discount rate to account for residual decline to life expectancy (78.7 years). Costs per QALY were calculated for both 1 year and life expectancy, assuming no loss of benefit. A 10,000 trial Monte Carlo simulation with probabilistic sensitivity analysis (PSA) assessed our model parameters and costs. RESULTS Three hundred sixty propensity matched patients (120 open, 120 MIS, 120 robotic) met inclusion criteria. Descriptive statistics for the cohort were: age 58.8±13.5, 50% women, BMI 29.4±6.3, operative time 294.4±119.0, LOS 4.56±3.31 days, estimated blood loss 515.9±670.0 cc, and 2.3±2.2 average levels fused. Rates of post-op complications were significantly higher in robotic cases versus open and MIS (43% vs. 21% and 22% for open and MIS, p .05). After factoring in complications, revisions, and purchasing and operating fees, the costs of robotic cases was significantly higher than both open and MIS surgery ($60,047.01 vs. $42,538.98 open and $41,471.21 MIS). In a subanalysis of 42 patients with baseline (BL) and 1Y EQ5D data, the cost per QALY at 1Y for open, MIS, and robot-assisted cases was $296,624.48, $115,911.69, and $592,734.30. If utility gained was sustained to life expectancy, the cost per QALY was $14,905.75, $5,824.71, $29,785.64 for open, MIS, and robot-assisted cases. Results of the PSA were consistent with MIS surgery having the most incremental cost effectiveness when compared to open and robotic surgery. CONCLUSIONS Numerous advances have been made in the field of spine surgery, however, there has been limited discussion of the effect these advances have on economic outcomes. When matched for levels fused, robot-assisted surgery patients had significantly higher rates of complications and 30% higher costs of surgery compared to minimally invasive and open spine surgery patients. While 1 year economic outcomes were not optimal for robotic surgery cases, the projected costs per QALYs at life expectancy were well below established acceptable thresholds. The above findings may be reflective of an educational learning curve and emerging surgical technologies undergoing progressive refinement.

Background: Adolescent idiopathic scoliosis (AIS) is a common cause of spinal deformity in adolescents. AIS can be associated with certain intraspinal anomalies such as syringomyelia (SM). This study assessed the rate o f SM in AIS patients and compared trends in surgical approach and postoperative outcomes in AIS patients with and without SM. Methods: The database was queried using ICD-9 codes for AIS patients from 2003–2012 (737.1–3, 737.39, 737.8, 737.85, and 756.1) and SM (336.0). The patients were separated into two groups: AIS-SM and AIS-N. Groups were compared using t-tests and Chi-squared tests for categorical and discrete variables, respectively. Results: Totally 77,183 AIS patients were included in the study (15.2 years, 64% F): 821 (1.2%) – AIS-SM (13.7 years, 58% F) and 76,362 – AIS-N (15.2 years, 64% F). The incidence of SM increased from 2003–2012 (0.9 to 1.2%, P = 0.036). AIS-SM had higher comorbidity rates (79 vs. 56%, P < 0.001). Comorbidities were assessed between AIS-SM and AIS-N, demonstrating significantly more neurological and pulmonary in AIS-SM patients. 41.2% of the patients were operative, 48% of AIS-SM, compared to 41.6% AIS-N. AIS-SM had fewer surgeries with fusion (anterior or posterior) and interbody device placement. AIS-SM patients had lower invasiveness scores (2.72 vs. 3.02, P = 0.049) and less LOS (5.0 vs. 6.1 days, P = 0.001). AIS-SM patients underwent more routine discharges (92.7 vs. 90.9%). AIS-SM had more nervous system complications, including hemiplegia and paraplegia, brain compression, hydrocephalous and cerebrovascular complications, all P < 0.001. After controlling for respiratory, renal, cardiovascular, and musculoskeletal comorbidities, invasiveness score remained lower for AIS-SM patients (P < 0.001). Conclusions: These results indicate that patients concordant with AIS and SM may be treated more cautiously (lower invasiveness score and less fusions) than those without SM.

BACKGROUND: The Miller et al adult spinal deformity frailty index (ASD-FI) correlates with complication risk; however, its development was not rooted in clinical outcomes, and the 40 factors needed for its calculation limit the index's clinical utility. The present study aimed to develop a simplified, weighted frailty index for ASD patients METHODS: This study is a retrospective review of a single-center database. Component ASD-FI parameters contributing to overall ASD-FI score were assessed via Pearson correlation. Top significant, clinically relevant factors were regressed against ASD-FI score to generate the modified ASD-FI (mASD-FI). Component mASD-FI factors were regressed against incidence of medical complications, and factor weights were calculated from regression of these coefficients. Total mASD-FI score ranged from 0 to 21, and was calculated by summing weights of expressed parameters. Linear regression and published ASD-FI cutoffs generated corresponding mASD-FI frailty cutoffs: not frail (NF, 12). Analysis of variance assessed the relationship between frailty category and validated baseline measures of pain and disability at baseline. RESULTS: The study included 50 ASD patients. Eight factors were included in the mASD-FI. Overall mean mASD-FI score was 5.7 ± 5.2. Combined, factors comprising the mASD-FI showed a trend of predicting the incidence of medical complications (Nagelkerke R(2) = 0.558; Cox & Snell R(2) = 0.399; P = .065). Breakdown by frailty category is NF (70%), frail (12%), and SF (18%). Increasing frailty category was associated with significant impairments in measures of pain and disability: Oswestry Disability Index (NF: 23.4; frail: 45.0; SF: 49.3; P < .001), SRS-22r (NF: 3.5; frail: 2.6; SF: 2.4; P = .001), Pain Catastrophizing Scale (NF: 41.9; frail: 32.4; SF: 27.6; P < .001), and NRS Leg Pain (NF: 2.3; frail: 7.2; SF: 5.6; P = .001). CONCLUSIONS: This study modifies an existing ASD frailty index and proposes a weighted, shorter mASD-FI. The mASD-FI relies less on patient-reported variables, and it weights component factors by their contribution to adverse outcomes. Because increasing mASD-FI score is associated with inferior clinical measures of pain and disability, the mASD-FI may serve as a valuable tool for preoperative risk assessment.

Background Although epidural steroid injection (ESI) may provide pain relief for patients with degenerative spondylolisthesis in treatment regimens of up to 4 months, it remains unclear whether ESI affects crossover from nonoperative to operative management. Methods This retrospective cohort study analyzed 2 groups of surgical candidates with degenerative spondylolisthesis: those who received ESI within 3 months after enrollment (ESI group) and those who did not (no-ESI group). Annual outcomes following enrollment were assessed within operative and nonoperative groups (patients who initially chose or were assigned to surgery or nonoperative treatment) by using longitudinal mixed-effect models with a random subject intercept term accounting for correlations between repeated measurements. Treatment comparisons were performed at follow-up intervals. Area-under-the-curve analysis for all time points assessed the global significance of treatment. Results The study included 192 patients in the no-ESI group and 74 in the ESI group. The no-ESI group had greater baseline Short Form-36 (SF-36) Bodily Pain scores (median, 35 versus 32) and self-reported preference for surgery (38% versus 11%). There were no differences in surgical rates within 4 years after enrollment between the no-ESI and ESI groups (61% versus 62%). The surgical ESI and no-ESI groups also showed no differences in changes in patient-reported outcomes at any follow-up interval or in the 4-year average. Compared with the nonoperative ESI group, the nonoperative no-ESI group showed greater improvements in SF-36 scores for Bodily Pain (p = 0.004) and Physical Function (p = 0.005) at 4 years, Bodily Pain at 1 year (p = 0.002) and 3 years (p = 0.005), and Physical Function at 1 year (p = 0.030) and 2 years (p = 0.002). Of the patients who were initially treated nonsurgically, those who received ESI and those who did not receive ESI did not differ with regard to surgical crossover rates. The rates of crossover to nonoperative treatment by patients who initially chose or were assigned to surgery also did not differ between the ESI and no-ESI groups. Conclusions There was no relationship between ESI and improved clinical outcomes over a 4-year study period for patients who chose or were assigned to receive surgery for degenerative spondylolisthesis. In the nonsurgical group, ESI was associated with inferior pain reduction through 3 years, although this was confounded by greater baseline pain. ESI showed little relationship with surgical crossover. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Obesity has risen to epidemic proportions within the United States. As the rates of obesity have increased, so has its prevalence among patients undergoing adult spinal deformity (ASD) surgery. The effect of obesity on the cost efficiency of corrective procedures for ASD has not been effectively evaluated.To investigate differences in cost efficiency of ASD surgery for patients stratified by body mass index (BMI).Retrospective review of a single-center ASD database.Five hundred five ASD patients.Complications, revisions, costs, EuroQol-5D (EQ5D), quality-adjusted life years (QALYs), cost per QALY.ASD patients (scoliosis≥20°, SVA≥5 cm, PT≥25°, or TK ≥60°) ≥18, undergoing ≥4 level fusions were included. Patients were stratified into NIH-defined obesity groups based on their preoperative BMI: underweight 18.5(U), normal 18.5 to 24.9 (N), overweight 25.0 to 29.9 (O), obese I 30.0 to 34.9 (OI), obese II 35.0 to 39.9 (OII), and obesity class III 40.0+ (OIII). Total surgery costs for each ASD obesity group were calculated. Costs were calculated using the PearlDiver database, which reflects both private insurance and Medicare reimbursement claims. Overall complications and major complications were assessed according to CMS definitions. QALYs and cost per QALY for obesity groups were calculated using an annual 3% discount up to life expectancy (78.7 years).In all, 505 patients met inclusion criteria. Baseline demographics and surgical details were: age 60.8±14.8, 67.6% female, BMI 28.8±7.30, 81.0% posterior approach, 18% combined approach, 10.1±4.2 levels fused, op time 441.2±146.1 minutes, EBL 1903.8±1594.7 cc, and LOS 8.7±10.7 days. There were 17 U, 154 N patients, 151 O patients, 100 OI, 51 OII, and 32 OIII patients. Revision rates by obesity group were: 0% U, 3% N patients, 3% O patients, 5% OI, 4% OII, and 6% for OIII patients. The total surgery costs by obesity group were: $48,757.86 U, $49,688.52 N, $47,219.93 O, $50,467.66 OI, $51,189.47 OII, and $53,855.79 OIII. In an analysis of patients with baseline and 1 Y EQ5D follow-up, the cost per QALY by obesity group was: $153,737.78 U, $229,222.37 N, $290,361.68 O, $493,588.47 OI, $327,876.21 OII, and $171,680.00 OIII. If that benefit was sustained to life expectancy, the cost per QALY was $8,588.70 U, $12,805.72 N, $16,221.32 O, $27,574.77 OI, $18,317.11 OII, and $9,591.06 for OIII.Among adult spinal deformity patients, those with BMIs in the obesity I, obesity II, or obesity class III range had more expensive total surgery costs. When assessing 1 year cost per QALY, obese patients had costs 32% higher than nonobese patients ($224,440.61 vs. $331,048.23). Further research is warranted on the utility of optimizing modifiable preoperative health factors for patients undergoing corrective adult spinal deformity surgery.

STUDY DESIGN Retrospective review. OBJECTIVE Identify co-occurring perioperative complications and associated predictors in a population of patients undergoing surgery for adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA Few studies have investigated the development of multiple, co-occurring complications following ASD-corrective surgery. Preoperative risk stratification may benefit from identification of factors associated with multiple, co-occurring complications. METHODS Elective ASD patients in National Surgical Quality Improvement Program (NSQIP) 2005 to 2016 were isolated; rates of co-occurring complications and affected body systems were assessed via cross tabulation. Random forest analysis identified top patient and surgical factors associated with complication co-occurrence, using conditional inference trees to identify significant cutoff points. Binary logistic regression indicated effect size of top influential factors associated with complication co-occurrence at each factor's respective cutoff point. RESULTS Included: 6486 ASD patients. The overall perioperative complication rate was 34.8%; 28.5% of patients experienced one complication, 4.5% experienced two, and 1.8% experienced 3+. Overall, 11% of complication co-occurrences were pulmonary/cardiovascular, 9% pulmonary/renal, and 4% integumentary/renal. By complication type, the most common co-occurrences were transfusion/urinary tract infection (UTI) (24.3%) and transfusion/pneumonia (17.7%). Surgical factors of operative time ≥400 minutes and fusion ≥9 levels were the strongest factors associated with the incidence of co-occurring complications, followed by patient-specific variables like American Society of Anesthesiologists (ASA) physical status classification grade ≥2 and age ≥65 years. Regression analysis further showed associations between increasing complication number and longer length of stay (LOS), (R2 = 0.202, P

Anterior cervical discectomy and fusion (ACDF) represents one of the most commonly performed spine surgeries. Dysphagia secondary to esophageal injury during retraction is one of the most common complications, and usually leads to self-limiting dysphagia. However, actual perforation and violation of the esophageal tissue is much rarer and can lead to delayed deep infections. Prevertebral abscess' are one of the most feared complications after ACDF, as they can lead to severe tissue swelling, osteomyelitis, hardware failure, and even death. Due to their rarity, a gold standard of workup and treatment is still unknown. A healthy 47-year-old female presents 9 months after a C4-C7 ACDF done at an outside institution with a large prevertebral abscess, osteomyelitis, hardware failure, and pseudoarthrosis secondary to esophagopharyngeal defect and prominent hardware. Overall, the patient underwent eight surgeries, and required an extended course of intravenous (IV) antibiotics, multiple diagnostic procedures, and complex soft tissue coverage using an anterolateral thigh free flap. Currently, the patient is doing well 6 months from her last procedure without any complications or plan for future surgery. This was an extremely rare case of a late occurring prevertebral abscess after ACDF. Dysphagia in the late postoperative setting should be evaluated carefully and thoroughly for any esophageal perforation and deep infection. As exemplified in this case, even partial thickness injuries to the esophageal-pharyngeal anatomy due to hardware irrigation can lead to catastrophic complications over time. Safe removal of all hardware anteriorly to avoid continued irritation of the esophagopharyngeal mucosa should be prioritized. If anterior hardware is necessary for stability, implants with the smallest footprint should be utilized. Early collaboration with ENT colleagues should be a priority and can provide crucial diagnostic and therapeutic interventions. Complex closure with a free flap was shown to be an effective way to provide successful definitive soft tissue coverage.

STUDY DESIGN Single institution retrospective clinical review. OBJECTIVE To investigate the relationship between levels fused and clinical outcomes in patients undergoing open and minimally invasive surgical (MIS) lumbar fusion. SUMMARY OF BACKGROUND DATA Minimally invasive spinal fusion aims to reduce the morbidity associated with conventional open surgery. As multilevel arthrodesis procedures are increasingly performed using MIS techniques, it is necessary to weigh the risks and benefits of multilevel MIS lumbar fusion as a function of fusion length. METHODS Patients undergoing

Spinal surgery in the ambulatory setting has gained popularity with providers, patients and healthcare systems due to its efficiency and cost advantages combined with comparable clinical results. With an increasing case variety and complexity performed in this setting, it is important to understand proper patient selection and preoperative preparation to minimize complications and optimize outcomes.

Study Design: Retrospective cohort study of prospective patients undergoing minimally invasive lumbar fusion at a single academic institution. Objective: To assess differences in perioperative outcomes between primary and revision MIS (minimally invasive surgical) lumbar interbody fusion patients and compare with those undergoing corresponding open procedures. Methods: Patients ≥18 years old undergoing lumbar interbody fusion were grouped by surgical technique: MIS or open. Patients within each group were propensity score matched for comorbidities and levels fused. Patient demographics, surgical factors, and perioperative complication incidences were compared between primary and revision cases using means comparison tests, as appropriate. Results: Of the 214 lumbar interbody fusion patients included after propensity score matching, 44 (21%) cases were MIS, and 170 (79%) were open. For MIS patients, there were no significant differences between primary and revision cases in estimated blood loss (EBL; 344 vs 299 cm3, P = .682); however, primary cases had longer operative times (301 vs 246 minutes, P = .029). There were no differences in length of stay (LOS), intensive care unit LOS, readmission, and intraoperative or postoperative complications (all P > .05). For open patients, there were no differences between primary and revision cases in EBL ( P > .05), although revisions had longer operative times (331 vs 278 minutes, P = .018) and more postoperative complications (61.7% vs 23.8%, P < .001). MIS revision procedures were shorter than open revisions (182 vs 213 minutes, P = .197) with significantly less EBL (294 vs 965 cm3, P < .001), shorter inpatient and intensive care unit LOS, and fewer postoperative complications (all P < .05). Conclusions: Clinical outcomes of revision MIS lumbar interbody fusion were similar to those of primary surgery. Additionally, MIS techniques were associated with less EBL, shorter LOS, and fewer perioperative complications than corresponding open revisions.

This study sought to assess comorbidity profiles unique to early-onset-scoliosis (EOS) patients by employing cluster analytics and to determine the influence of isolated comorbidity clusters on perioperative complications, morbidity and mortality using a high powered administrative database. The KID database was queried for ICD-9 codes pertaining to congenital and idiopathic scoliosis from 2003, 2006, 2009, 2012. Patients10 y/o (EOS group) were included. Demographics, incidence and comorbidity profiles were assessed. Comorbidity profiles were stratified by body systems (neurological, musculoskeletal, pulmonary, cardiovascular, renal). K-means cluster and descriptive analyses elucidated incidence and comorbidity relationships between frequently co-occurring comorbidities. Binary logistic regression models determined predictors of perioperative complication development, mortality, and extended length-of-stay (≥75th percentile). 25,747 patients were included (Age: 4.34, Female: 52.1%, CCI: 0.64). Incidence was 8.9 per 100,000 annual discharges. 55.2% presented with pulmonary comorbidities, 48.7% musculoskeletal, 43.8% neurological, 18.6% cardiovascular, and 11.9% renal; 38% had concurrent neurological and pulmonary. Top inter-bodysystem clusters: Pulmonary disease (17.2%) with epilepsy (17.8%), pulmonary failure (12.2%), restrictive lung disease (10.5%), or microcephaly and quadriplegia (2.1%). Musculoskeletal comorbidities (48.7%) with renal and cardiovascular comorbidities (8.2%, OR: 7.9 [6.6-9.4], p 0.001). Top intra-bodysystem clusters: Epilepsy (11.7%) with quadriplegia (25.8%) or microcephaly (20.5%). Regression analysis determined neurological and pulmonary clusters to have a higher odds of perioperative complication development (OR: 1.28 [1.19-1.37], p 0.001) and mortality (OR: 2.05 [1.65-2.54], p 0.001). Musculoskeletal with cardiovascular and renal anomalies had higher odds of mortality (OR: 1.72 [1.28-2.29], p 0.001) and extLOS (OR: 2.83 [2.48-3.22], p 0.001). EOS patients with musculoskeletal conditions were 7.9x more likely to have concurrent cardiovascular and renal anomalies. Clustered neurologic and pulmonary anomalies increased mortality risk by as much as 105%. These relationships may benefit pre-operative risk assessment for concurrent anomalies and adverse outcomes. Level of Evidence: III - Retrospective Prognostic Study.

The Clavien-Dindo grading allows for broad comparison of perioperative surgical complications, and a temporal analysis of complications following ASD-corrective surgery. NSQIP database was utilized from 2010 to 2014 to isolate patients. Complications were stratified by Clavien complication (Cc) grade, and patients grouped by highest Cc grade: I, II, III, IV, V. Secondary analysis grouped by minor (I, II, III) and severe (IV, V). Comorbidity burden was assessed with a NSQIP-modified Charlson Comorbidity Index (CCI) and frailty was measured with a 5-factor modified frailty index (mFI). From 2010 to 2014, 2971 patients (57 yrs, 58% F) underwent surgery for ASD (3.4 ± 4.1 levels; surgical approach: 46% anterior, 44% posterior, 10% combined), the rate of which increased 0.01% to 0.13. 32% suffered >1 complication. Patient breakdown by Cc grade: 0% I, 25% II, 3% III, 4% IV, 1% V. Severe Cc patients were more comorbid than minor Cc (CCI 2.8 vs 1.8), had longer operative times (394 min vs 251), and higher rates of osteotomy (29% vs 13%) and iliac fixation (16% vs 5%). Overall CCI (2.1–1.7) and perioperative complication rates (55–29%) decreased, despite increasing surgical invasiveness (2.8–4.5) and increasing frailty score (0.14 ± 0.15 vs 0.16 ± 0.16). Rates of Clavien grade II (39.80–22.20%) and IV (9.40–3.50%) complications also decreased, indicative of surgical improvements and effective preoperative patient selection. The decrease in CCI and increase in the modified frailty score may show that we are becoming more cognizant of discerning of comorbidities, but likely to not to have taken into account frailty, which may have an impact on future health socioeconomics.

BACKGROUND: The Patient-Reported Outcome Measurement Information System (PROMIS) and legacy outcome measures like the Oswestry Disability Index (ODI) have not been compared for their sensitivity in reflecting the impact of perioperative complications and length of stay (LOS) in a surgical thoracolumbar population. The purpose of this study is to assess the strength of PROMIS and ODI scores as they correlate with LOS and complication outcomes of surgical thoracolumbar patients. METHODS: Retrospective cohort study. Included: patients ≥18 years undergoing thoracolumbar surgery with available preoperative and 3-month postoperative ODI and PROMIS scores. Pearson correlation assessed the linear relationships between LOS, complications, and scores for PROMIS (physical function, pain intensity, pain interference) and ODI. Linear regression predicted the relationship between complication incidence and scores for ODI and PROMIS. RESULTS: Included: 182 patients undergoing thoracolumbar surgery. Common diagnoses were stenosis (62.1%), radiculopathy (48.9%), and herniated disc (47.8%). Overall, 58.3% of patients underwent fusion, and 50.0% underwent laminectomy. Patients showed preoperative to postoperative improvement in ODI (50.2 to 39.0), PROMIS physical function (10.9 to 21.4), pain intensity (92.4 to 78.3), and pain interference (58.4 to 49.8, all P < .001). Mean LOS was 2.7 ± 2.8 days; overall complication rate was 16.5%. Complications were most commonly cardiac, neurologic, or urinary (all 2.2%). Whereas preoperative to postoperative changes in ODI did not correlate with LOS, changes in PROMIS pain intensity (r = 0.167, P = .024) and physical function (r = −0.169, P = .023) did. Complications did not correlate with changes in ODI or PROMIS score; however, postoperative scores for physical function (r = −0.205, P = .005) and pain interference (r = 0.182, P = .014) both showed stronger correlations with complication occurrence than ODI (r = 0.143, P = .055). Regression analysis showed postoperative physical function (R(2) = 0.037, P = .005) and pain interference (R(2) = 0.028, P = .014) could predict complications; ODI could not. CONCLUSIONS: PROMIS domains of physical function and pain interference better reflected perioperative complications and LOS than the ODI. These results suggest PROMIS may offer more utility as an outcomes assessment instrument. LEVEL OF EVIDENCE: 3.

Study design Retrospective cohort study. Objective This study aimed to evaluate the utility of the modified frailty index (mFI-5) in a population of patients undergoing spine surgery. Summary of background data The original modified frailty index (mFI-11) published as an American College of Surgeons National Surgical Quality Improvement Program 11-factor index was modified to mFI-5 after variables were removed from recent renditions. Methods Surgical spine patients were isolated using current procedural terminology codes. mFI-11 (11) and mFI-5 (5) were calculated from 2005 to 2012. mFI was determined by dividing the factors present by available factors. To assess correlation, Spearman rho was used. Predictive values of indices were generated by binary logistic regression. Patients were stratified into groups by mFI-5: not frail (NF, 0.5). Means comparison tests analyzed frailty and clinical outcomes. Results After calculating the mFI-5 and the mFI-11, Spearman rho between the two indices was 0.926(P 0.05). With increase in severity, postoperative rates of morbidities and complications increased. Conclusion The five-factor National Surgical Quality Improvement Program modified frailty index is an effective predictor of postoperative events following spine surgery. Severity of frailty score by the mFI-5 was associated with increased morbidity and mortality. The mFI-5 within a surgical spine population can reliably predict post-op complications. This tool is less cumbersome than mFI-11 and relies on readily accessible variables at the time of surgical decision-making.Level of Evidence: 3.

Study Design: Retrospective review of single institution. Objective: To assess the relationship between Patient-Reported Outcomes Measurement Information System (PROMIS) and Oswestry Disability Index (ODI) scores in thoracolumbar patients. Methods: Included: Patients ≥18 years with a thoracolumbar spine condition (spinal stenosis, disc herniation, low back pain, disc degeneration, spondylolysis). Bivariate correlations assessed the linear relationships between ODI and PROMIS (Physical Function, Pain Intensity, and Pain Interference). Correlation cutoffs assessed patients with high and low correlation between ODI and PROMIS. Linear regression predicted the relationship of ODI to PROMIS. Results: A total of 206 patients (age 53.7 ± 16.6 years, 49.5% female) were included. ODI correlated with PROMIS Physical Function ( r = −0.763, P < .001), Pain Interference ( r = 0.800, P < .001), and Pain Intensity ( r = 0.706, P < .001). ODI strongly predicted PROMIS for Physical Function ( R2 = 0.58, P < .001), Pain Intensity ( R2 = 0.50, P < .001), and Pain Interference ( R2 = 0.64, P < .001); however, there is variability in PROMIS that ODI cannot account for. ODI questions about sitting and sleeping were weakly correlated across the 3 PROMIS domains. Linear regression showed overall ODI score as accounting for 58.3% ( R2 = 0.583) of the variance in PROMIS Physical Function, 63.9% ( R2 = 0.639) of the variance in Pain Interference score, and 49.9% ( R2 = 0.499) of the variance in Pain Intensity score. Conclusions: There is a large amount of variability with PROMIS that cannot be accounted for with ODI. ODI questions regarding walking, social life, and lifting ability correlate strongly with PROMIS while sitting, standing, and sleeping do not. These results reinforce the utility of PROMIS as a valid assessment for low back disability, while indicating the need for further evaluation of the factors responsible for variation between PROMIS and ODI.

Background: Informed patient selection and counseling is key in improving surgical outcomes. Understanding the impact that certain baseline variables can have on postoperative outcomes is essential in optimizing treatment for certain symptoms, such as radiculopathy from cervical spine pathologies. The aim was to identify baseline characteristics that were related to improved or worsened postoperative outcomes for patients undergoing surgery for cervical spine radiculopathic pain. Methods: Retrospective review of prospectively collected data. Patient Sample: Surgical cervical spine patients with a diagnosis classification of “degenerative.” Diagnoses included in the “degenerative” category were those that caused radiculopathy: cervical disc herniation, cervical stenosis, and cervical spondylosis without myelopathy. Baseline variables considered as predictors were: (1) age, (2) body mass index (BMI), (3) gender, (4) history of cervical spine surgery, (5) baseline Neck Disability Index (NDI) score, (6) baseline SF-36 Physical Component Summary (PCS) scores, (7) baseline SF-36 Mental Component Summary (MCS) scores, (8) Visual Analog Scale (VAS) Arm score, and (9) VAS Neck. Outcome Measures: Improvement in NDI (≥50%), VAS Arm/Neck (≥50%), SF-36 PCS/MCS (≥10%) scores at 2-years postoperative. An arm-to-neck ratio (ANR) was also generated from baseline VAS scores. Univariate and multivariate analyses evaluated predictors for 2-year postoperative outcome improvements, controlling for surgical complications and technique. Results: Three hundred ninety-eight patients were included. Patients with ANR ≤ 1 (n = 214) were less likely to reach improvements in 2-year NDI (30.0% vs 39.2%, P = .050) and SF-36 PCS (42.4% vs 53.5%, P = .025). Multivariate analysis for neck disability revealed higher baseline SF-36 PCS (odds ratio [OR] 1.053) and MCS (OR 1.028) were associated with over 50% improvements. Higher baseline NDI were reduced odds of postoperative neck pain improvement (OR 0.958). Arm pain greater than neck pain at baseline was associated with both increased odds of postoperative arm pain improvement (OR 1.707) and SF36 PCS improvement (OR 1.495). Conclusions: This study identified specific symptom locations and health-related quality of life (HRQL) scores, which were associated with postoperative pain and disability improvement. In particular, baseline arm pain greater than neck pain was determined to have the greatest impact on whether patients met at least 50% improvement in their upper body pain score. These findings are important for clinicians to optimize patient outcomes through effective preoperative counseling.

Study design Retrospective analysis of prospective data from the degenerative spondylolisthesis (DS) arm of the Spine Patient Outcomes Research Trial. Objective The aim of this study was to identify risk factors for reoperation in patients treated surgically for DS and compare outcomes between patients who underwent reoperation with nonreoperative patients. Summary of background data Several studies have examined outcomes following surgery for DS, but few have identified risk factors for reoperation. Methods Analysis included patients with neurogenic claudication (>12 weeks), clinical neurological signs, spinal stenosis, and DS on standing lateral x-rays. Univariate and multivariate analyses were used to investigate patient characteristics and risk factors. Treatment effects (TEs) were calculated and compared between study groups. Results Of 406 patients, 72% underwent instrumented fusion, 21% noninstrumented fusion, and 7% decompression alone. At 8 years, the reoperation rate was 22%, of which 28% occurred within 1 year, 54% within 2 years, 70% within 4 years, and 86% within 6 years. The reasons for reoperation included recurrent stenosis or progressive spondylolisthesis (45%), complications such as hematoma, dehiscence, or infection (36%), or new condition (14%). Reoperative patients were younger (62.2 vs. 65.3, P = 0.008). Significant risk factors were use of antidepressants (P = 0.008, hazard ratio [HR] 2.08) or having no neurogenic claudication upon enrollment (P = 0.02, HR 1.82). Patients who were smokers, diabetics, obese, or on workman's compensation were not at greater risk for reoperation. At 8-year follow-up, scores for SF-36 bodily pain (BP), Oswestry Disability Index, American Academy of Orthopaedic Surgeons/Modems version (ODI), and stenosis frequency index were better in nonreoperative patients. TE favored nonreoperative patients for SF-36 BP, physical function, ODI, Stenosis Bothersomeness Index, and satisfaction with symptoms (P Conclusion The incidence of reoperation for patients with DS was 22% 8 years following surgery. Patients with a history of no neurogenic claudication and patients taking antidepressants were more likely to undergo reoperation. Outcome scores and TE were more favorable in nonreoperative patients. Level of evidence 2.

STUDY DESIGN A retrospective review of a prospectively collected database, the Nationwide Inpatient Sample (NIS), years 2003 to 2012. OBJECTIVES The aim of this study was to examine trends in the management of scoliosis in elderly (age >75 yrs) patients from 2003 to 2012. SUMMARY OF BACKGROUND DATA Scoliosis incidence rises with increasing age, and age has been shown to be an independent risk factor for surgical complications in scoliosis surgery. Previous studies have displayed increasing surgical frequency on elderly scoliotic patients in the last decade, but have not investigated complications in the same years. METHODS ICD-9 coding identified elderly (age ≥75 yrs) patients with a primary diagnosis of scoliosis undergoing lumbar fusion or decompression. Analysis of variance (ANOVA) comparisons and linear trend analysis described changes from 2003 to 2012 in surgical invasiveness (Mirza scale: levels fused/decompressed/instrumented and by approach), intraoperative complications, and Charlson Comorbidity Index (CCI). Secondary outcome measures included cost and discharge outcomes. RESULTS Eight thousand one elderly patients with ASD from 2003 to 2012 were included for analysis. Fusion incidence increased on average 13.8% per year (P

There has been limited discussion as to whether spine surgery patients are benefiting from shorter in-patient hospital stays or if they are incurring higher rates of readmission and complications secondary to shortened length of stays. Included in this study were 237,446 spine patients >18yrs and excluding infection. Patients with Clavien Grade 5 complications in 2015 had the lowest mean time to readmission after initial surgery in all years at 12.44 ± 9.03 days. Pearson bivariate correlations between LOS ≤ 1 day and decreasing days to readmission was the strongest in 2016.). Logistic regression analysis found that LOS ≤ 1 day showed an overall increase in the odds of hospital readmission from 2012 to 2016 (2.29 [2.00–2.63], 2.33 [2.08–2.61], 2.35 [2.11–2.61], 2.27 [2.06–2.49], 2.33 [2.14–2.54], all p

The aim of this study was to investigate the cost utility of treating non-frail versus frail or severely frail adult spinal deformity (ASD) patients. 79 surgical ASD patients >18 years with available frailty and ODI data at baseline and 2-years post-surgery (2Y) were included. Utility data was calculated using the ODI converted to the SF-6D. QALYs utilized a 3% discount rate to account for decline to life expectancy (LE). Costs were calculated using the PearlDiver database. ICER was compared between non-operative (non-op.) and operative (op.) NF and F/SF patients at 2Y and LE. When compared to non-operative ASD, the ICER was $447,943.96 vs. $313,211.01 for NF and F/SF at 2Y, and $68,311.35 vs. $47,764.61 for NF and F/SF at LE. Frail and severely frail patients had lower cost per QALY compared to not frail patients at 2Y and life expectancy, and had lower ICER values when compared to a non-operative cohort of ASD patients. While these results support operative correction of frail and severely frail patients, it is important to note that these patients are often at worse baseline disability, which is closely related to frailty scores, and have more opportunity to improve postoperatively. Furthermore, there may be a threshold of frailty that is not operable due to the risk of severe complications that is not captured by this analysis. While future research should investigate economic outcomes at extended follow up times, these findings support the cost effectiveness of ASD surgery at all frailty states.

BACKGROUND: Regional and segmental changes of the lumbar spine have previously been described as patients transition from standing to sitting; however, alignment changes in the cervical and thoracic spine have yet to be investigated. So, the aim of this study was to assess cervical and thoracic regional and segmental changes in patients with thoracolumbar deformity versus a nondeformed thoracolumbar spine population. METHODS: This study was a retrospective cohort study of a single center's database of full-body stereoradiographic imaging and clinical data. Patients were ≥ 18 years old with nondeformed spines (nondegenerative, nondeformity spinal pathologies) or thoracolumbar deformity (ASD: PI-LL > 10°). Patients were propensity-score matched for age and maximum hip osteoarthritis grade and were stratified by Scoliosis Research Society (SRS)–Schwab classification by PI-LL, SVA, and PT. Patients with lumbar transitional anatomy or fusions were excluded. Outcome measures included changes between standing and sitting in global alignment parameters: sagittal vertical axis (SVA), pelvic incidence minus lumbar lordosis (PI-LL), pelivc tilt (PT), thoracic kyphosis, cervical alignment, cervical SVA, C2-C7 lordosis (CL), T1 slop minus CL (TS-CL), and segmental alignment from C2 to T12. Another analysis was performed using patients with cervical and thoracic segmental measurements. RESULTS: A total of 338 patients were included (202 nondeformity, 136 ASD). After propensity-score matching, 162 patients were included (81 nondeformity, 81 ASD). When categorized by SRS-Schwab classification, all nondeformity patients were nonpathologically grouped for PI-LL, SVA, and PT, whereas ASD patients had mix of moderately and markedly deformed modifiers. There were significant differences in pelvic and global spinal alignment changes from standing to sitting between nondeformity and ASD patients, particularly for SVA (nondeformed: 49.5 mm versus ASD: 27.4 mm; P&thinsp

STUDY DESIGN This was a retrospective cohort study. OBJECTIVE The aim of this study was to investigate associations between time to surgical intervention and outcomes for central cord syndrome (CCS) patients. BACKGROUND As surgery is increasingly recommended for patients with neurological deterioration CCS, it is important to investigate the relationship between time to surgery and outcomes. MATERIALS AND METHODS CCS patients were isolated in Nationwide Inpatient Sample database 2005-2013. Patients were grouped by time to surgery: same-day, 1-day delay, 2, 3, 4-7, 8-14, and >14 days. Means comparison tests compared patient factors, perioperative complications, and charges across patient groups. Controlling for age, comorbidities, length of stay, and concurrent traumatic fractures, binary logistic regression assessed surgical timing associated with increased odds of perioperative complication, using same-day as reference group. RESULTS Included: 6734 CSS patients (64% underwent surgery). The most common injury mechanisms were falls (30%) and pedestrian accidents (7%). Of patients that underwent surgery, 52% underwent fusion, 30% discectomy, and 14% other decompression of the spinal canal. Breakdown by time to procedure was: 39% same-day, 16% 1-day, 10% 2 days, 8% 3 days, 16% 4-7 days, 8% 8-14 days, and 3% >14 days. Timing groups did not differ in trauma status at admission, although age varied: [minimum: 1 d (58±15 y), maximum: >14 d (63±13 y)]. Relative to other groups, same-day patients had the lowest hospital charges, highest rates of home discharge, and second lowest postoperative length of stay behind 2-day delay patients. Patients delayed >14 days to surgery had increased odds of perioperative cardiac and infection complications. Timing groups beyond 3 days showed increased odds of VTE and nonhome discharge. CONCLUSIONS CCS patients undergoing surgery on the same day as admission had lower odds of complication, hospital charges, and higher rates of home discharge than patients that experienced a delay to operation. Patients delayed >14 days to surgery were associated with inferior outcomes, including increased odds of cardiac complication and infection.

In the current value-based healthcare climate where spine surgery is shifting to the ambulatory setting, factors influencing postop length of stay (LOS) are important to surgeons and hospital administrators. Pre-op patient factors including diagnosis of radiculopathy and myelopathy have yet to be investigated in this context. Operative pts ≥ 18Y with primary diagnoses of cervical myelopathy (M), radiculopathy (R), or myeloradiculopathy (MR) were included and propensity score matched by invasiveness score (Mirza et al.). Top-quartile LOS was defined as extended. M&R patients were compared using Chi2 & independent t-tests. Univariate tests assessed differences in preop patient and surgical data in M&R pts and extended/non-extended LOS. Stepwise regression analysis explored factors predictive of LOS. 718 operative pts (54.5 yrs, 41.1%F, 29.1 kg/m2, mean CCI 1.11) included (177 M, 383 R, and 158 MR). After PSM, 345 patients remained (115 in each diagnosis). 102 patients had E-LOS (Avg: 5.96 days), 41 M patients (mean 7.1 days), 28 R (5.9 days), and 33 MR (4.6 days). Regression showed predictors of E-LOS in R pts (R2 = 0.532, p = 0.043): TS-CL, combined and posterior approach, LIV, UIV, op time, Lactated Ringer’s, postoperative complications. Predictors of E-LOS in M pts (R2 = 0.230, p

Background: The study aimed to characterize trends in incidence, etiology, fracture types, surgical procedures, complications, and concurrent injuries associated with traumatic pediatric cervical fracture using a nationwide database. Methods: The Kids9 Inpatient Database (KID) was queried. Trauma cases from 2003 to 2012 were identified, and cervical fracture patients were isolated. Demographics, etiologies, fracture levels, procedures, complications, and concurrent injuries were assessed. The t-tests elucidated significance for continuous variables, and χ2 for categoric values. Logistic regressions identified predictors of spinal cord injury (SCI), surgery, any complication, and mortality. Level of significance was P Results: A total of 11 196 fracture patients were isolated (age, 16.63 years; male, 65.7%; white, 65.4%; adolescent, 55.4%). Incidence significantly increased since 2003 (2003 vs 2012, 2.39% vs 3.12%, respectively), as did Charlson Comorbidity Index (CCI; 2003 vs 2012, 0.2012 vs 0.4408, respectively). Most common etiology was motor vehicle accidents (50.5%). Infants and children frequently fractured at C2 (closed: 43.1%, 32.9%); adolescents and young adults frequently fractured at C7 (closed: 23.9%, 26.5%). Upper cervical SCI was less common (5.8%) than lower cervical SCI (10.9%). Lower cervical unspecified-SCI, anterior cord syndrome, and other specified SCIs significantly decreased since 2003. Complications were common (acute respiratory distress syndrome, 7.8%; anemia, 6.7%; shock, 3.0%; and mortality, 4.2%), with bowel complications, cauda equina, anemia, and shock rates significantly increasing since 2003. Concurrent injuries were common (15.2% ribs; 14.4% skull; 7.1% pelvis) and have significantly increased since 2003. Predictors of SCI included sports injury and CCI. Predictors of surgery included falls, sports injuries, CCI, length of stay, and SCI. CCI, SCIs, and concurrent injuries were predictors of any complication and mortality, all (P Conclusions: Since 2003, incidence, complications, concurrent injuries, and fusions have increased. CCI, SCI, falls, and sports injuries were significant predictors of surgical intervention. Decreased mortality and SCI rates may indicate improving emergency medical services and management guidelines. Level of Evidence: III Clinical Relevance: Clinicians should be aware of increased case complexity in the onset of added perioperative complications and concurrent injuries. Cervical fractures resultant of sports injuries should be scrutinized for concurrent SCIs.

Introduction This study assessed the incidence and risk factors for pseudarthrosis among primary spine fusion patients. Methods Retrospective review of ACS-NSQIP (2005–2013). Differences in comorbidities between spine fusion patients with and without pseudarthrosis (Pseud, N-Pseud) were assessed using chi-squared tests and Independent Samples t-tests. Binary logistic regression assessed patient-related and procedure-related predictors for pseudarthrosis. Results 52,402 patients (57yrs, 53%F, 0.4% w/pseudarthrosis). Alcohol consumption (OR:2.6[1.2–5.7]) and prior history of surgical revision (OR:1.6[1.4–1.8]) were risk factors for pseudarthrosis operation. Pseud patients at higher risk for deep incisional SSI (at 30-days:OR:6.6[2.0–21.8]). Pseud patients had more perioperative complications (avg:0.24 ± 0.43v0.18 ± 0.39,p=0.026). Conclusions Alcoholism and surgical revision are major risk factors for pseudarthrosis in patients undergoing spine fusion.

Study design A retrospective subgroup analysis was performed on surgically treated patients from the lumbar spinal stenosis (SpS) arm of the Spine Patient Outcomes Research Trial (SPORT), randomized, and observational cohorts. Objective To identify risk factors for reoperation in patients treated surgically for SpS and compare outcomes between patients who underwent reoperation with those who did not. Summary of background data SpS is one of the most common indications for surgery in the elderly; however, few long-term studies have identified risk factors for reoperation. Methods A post-hoc subgroup analysis was performed on patients from the SpS arm of the SPORT, randomized and observational cohorts. Baseline characteristics were analyzed between reoperation and no-reoperation groups using univariate and multivariate analysis on data 8 years postoperation. Results Of the 417 study patients, 88% underwent decompression only, 5% noninstrumented fusion, and 6% instrumented fusion. At the 8-year follow-up, the reoperation rate was 18%; 52% of reoperations were for recurrent stenosis or progressive spondylolisthesis, 25% for complication or other reason, and 16% for new condition. Of patients who underwent a reoperation, 42% did so within 2 years, 70% within 4 years, and 84% within 6 years. Patients who underwent reoperation were less likely to have presented with any neurological deficit (43% reop vs. 57% no reop, P = 0.04). Patients improved less at follow-up in the reoperation group (P Conclusion In patients undergoing surgical treatment for SpS, the reoperation rate at 8-year follow-up was 18%. Patients with a reoperation were less likely to have a baseline neurological deficit. Patients who did not undergo reoperation had better patient reported outcomes at 8-year follow-up compared with those who had repeat surgery. Level of evidence 2.

Background: This study aims to describe properties of adult spinal deformity (ASD) revisions relative to primary surgeries and determine clinical variables that can predict revision. ASD is a common pathology that can lead to decreased quality of life, pain, physical limitations, and dissatisfaction with self-image. Durability of interventions for deformity treatment is of paramount concern to surgeons, as revision rates remain high. Methods: Patients undergoing thoracolumbar fusion, five or more levels, for scoliosis (primary diagnosis ICD-9 737.x) were identified on a state-wide database. Primary and revision (returning for re-fusion procedure) surgeries were compared based on demographic, hospital stay, and clinical characteristics. Differences between primary and revision surgeries, and predictors of primary surgeries requiring revision, utilized binary logistic regression controlling for age, comorbidity burden, and levels fused. Results: A total of 1,063 patients (average 7.4 levels fused, mean age: 47.6 years, 69.0% female) undergoing operative treatment for ASD were identified, of which 123 (average 7.1 levels fused, 11.6%, mean age 61.43, 80.5% female) had surgical revision. Primary surgeries were ~0.3 levels longer (P=0.013), used interbody ~11% more frequently (P=0.020), and used BMP ~12% less frequently (P=0.008). Revisions occurred 176.4 days after the primary on average. The most frequent causes of revisions were: 43.09% implant failure, 24.39% acquired kyphosis, and 14.63% enduring scoliosis. After controlling for age, comorbidities, and levels fused older, more comorbid, female, and white-race patients were more likely to be revised. Upon multivariate regression, after controlling for age and levels fused, overall complications remained non-different (OR: 0.8, 95% CI: 0.6–1.2). However, revision remained an independent predictor for infection (OR: 5.5, 95% CI: 2.8–10.5). Conclusions: In a statewide database with individual patient follow up of up to 4 years 10% of ASD patients undergoing scoliosis correction required revision. Revision surgeries had higher infection incidence.

BACKGROUND CONTEXT In the current value-based health care climate where spinal surgery is shifting to the ambulatory setting, factors influencing postoperative patient length of stay (LOS) have significance to both surgeons and hospital administrators. Underlying patient factors including the diagnosis of radiculopathy and myelopathy have not been investigated in this context. PURPOSE Identify predictors extended LOS(E-LOS) between myelopathy(M), radiculopathy(R), and patients with both (MR). STUDY DESIGN/SETTING Retrospective review of a single-center stereographic database. PATIENT SAMPLE A total of 718 surgical cervical spine patients. OUTCOME MEASURES Postoperative LOS, patient factors, preoperative HRQL, complications, predictors of E-LOS. METHODS Surgical cervical spine patients ≥18yrs diagnosed with M or R primary diagnoses were isolated in the single-center Comprehensive Spine Quality Database (Quality). Patients were stratified by surgical approach: Anterior, Posterior or Combined. Top-quartile LOS values were labeled as extended. M and R patients were compared using chi-squared and independent samples t-tests, as appropriate. Univariate tests assessed differences in baseline patient-related and surgical data between M and R, and extended/non-extended LOS. Univariate/multivariate analyses were run to assess predictive factors of E-LOS in each diagnosis group. Regression with stepwise model selection was employed to explore factors potentially significant in predicting LOS. RESULTS A total of 718 patients (54.5 years, 41.1%F, 29.1kg/m2). Mean CCI score: 1.11. Within the cohort, 177 patients (24.7%) had a diagnosis of myelopathy, 383 (53.3%) radiculopathy, and 22% with a diagnosis of myeloradiculopathy. Patients with M primary diagnosis were significantly older (62.2 vs 49.8yrs, p CONCLUSIONS Independent of surgical approach, patients with a primary diagnosis of myelopathy, though older aged and higher comorbidity profile, had consistently longer overall postop LOS when compared to radiculopathy or myeloradiculopathy patients. The heightened risk in myelopathy patients for extended LOS should be considered when determining admission status for patients undergoing cervical spine surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT The Roussouly Classification system of sagittal spinal shape and the SRS-Schwab adult spinal deformity (ASD) classification system have become important indicators of spine deformity. No prior studies have examined the outcomes of matching both Roussouly type and improving in Schwab modifiers postoperatively. PURPOSE Evaluate outcomes of matching Roussouly Type and improving in Schwab modifier following ASD surgery. STUDY DESIGN/SETTING Retrospective review of single-center ASD database. PATIENT SAMPLE A total of 103 ASD patients. OUTCOME MEASURES Roussouly types, Schwab modifiers, Health Related Quality of Life scores(HRQLs): Minimal Clinical Important Difference for ODI, EQ5D, VAS Leg B Type 2: PI 60°); (2) “current” Roussouly type (1: SS 45°), as previously published. One year (1Y) matched Roussouly: preoperative mismatched (Between ‘actual’ and ‘theoretical’ patients that matched at 1Y. Schwab modifiers at BL were identified: non-, moderate and severe deformity (0, +, ++) for PT, SVA, and PI-LL. Schwab improvement was defined as a decrease in a modifier at one year. RESULTS A total of 103 ASD patients (61.8yrs, 63.1%F, 30kg/m2). By surgical approach, 79.6% posterior, 10.7% combined, 2.9% anterior). Average levels fused: 4.6. BL breakdown of ‘current; Roussouly type: 28% Type 1, 25.3% Type 2, 32.0% Type 3, 14.7% Type 4. BL Roussouly mismatch: 65.3%. Breakdown BL Schwab modifiers: PT (0: 8.7%, +: 41.7%, ++: 49.5%), SVA (0: 29.7%, +: 20.3%, ++: 50%), PI-LL mismatch (0: 28.2%, +: 25.2%, ++: 46.6%). At one year, 19.2% of patients matched Roussouly target type, while according to Schwab modifiers, 12.6% improved in SVA, 42.7% in PI-LL, and 45.6% in PT. Patients who both met Roussouly type and improved in a Schwab by the modifiers: 9 PT (8.7%), 8 PI-LL (7.8%), 2 SVA (1.9%). There were 2 patients (1.9%) who met their Roussouly type and improved in all 3 Schwab modifiers. One year (1Y) matched Roussouly patients improved more in HRQLs (MCID for ODI, EQ5D, VAS Leg/Back Pain), when compared to mismatched Roussouly, but was not significant(P>0.05). Match Roussouly and improvement in PT Schwab met MCID for EQ5D significantly more (33.3% vs 10.6%, p=0.050). Matched Roussouly and PI-LL Schwab had more patients meet MCID for all HRQLs, yet none were significant, p>0.05. Matched Roussouly and improvement in SVA Schwab met MCID for ODI significantly more (p=0.024). CONCLUSIONS Patients who both matched Roussouly sagittal spinal type and improved in SRS-Schwab modifiers had superior patient-reported outcomes at 1-year. Utilizing both classification systems in surgical decision making can optimize postop patient outcomes. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Although epidural steroid injection (ESI) has been shown to provide adequate pain relief for degenerative spondylolisthesis patients in treatment regimens up to months, it remains unclear whether the use of ESI affects the rate of crossover from nonoperative to operative management. PURPOSE Investigate the relationship between epidural steroid injections and rates of surgical crossover for degenerative spondylolisthesis patients. STUDY DESIGN/SETTING Retrospective review of prospectively collected data from 13 spine centers. PATIENT SAMPLE Degenerative spondylolisthesis patients from both the randomized and concurrent observational cohorts of the Spine Patient Outcomes Research Trial (SPORT). OUTCOME MEASURES Primary: Surgical crossover rates. Secondary: health related quality of life outcome (HRQL) measures (SF-36, ODI, Sciatica and Leg Pain Bothersomeness Indices), self-reported improvement METHODS Included: surgical candidates >18yrs with degenerative spondylolisthesis. Excluded: patients receiving ESI before enrollment. Those who received ESI within 3 months of enrollment (ESI) and those who did not (no-ESI) were compared for differences in baseline characteristics. Outcomes at 1-year, 2-year, 3-year, and 4-year intervals following enrollment were assessed within operative and nonoperative groups using longitudinal mixed–effect models with random subject intercept term to account for correlations between repeated measurements. Treatment comparisons were performed at follow-up intervals. Area under the curve analysis for all time points assessed global significance of treatment. RESULTS Included: 266 patients (192 no-ESI, 74 ESI). Patient groups did not differ in age, sex, BMI, or comorbidity burden (all p>0.05). No-ESI had greater baseline SF-36 body-pain scores (38±20 vs 30±16, p=0.002) and self-reported surgical preference (38% vs 11%, p 0.05). Surgical ESI and no-ESI patients showed no differences in postoperative HRQL changes at any follow-up interval, or in 4-year average HRQL outcomes. Non-operative no-ESI patients showed greater 4-year average improvement in SF-36 body pain (no-ESI: 17.8, ESI: 7.8, p=0.004) and physical function (no-ESI: 13.1, ESI: 4.3, p=0.005) than non-operative ESI patients. These improvements in SF-36 body pain were greater for non-operative no-ESI patients at 1-year (p=0.002) and 3-years (p=0.005); improvements in SF-36 physical function were greater for non-operative no-ESI patients at 1-year (p=0.030) and 2-years (p=0.002). Of patients that were initially non-operative, there was no difference between ESI and no-ESI groups in surgical crossover rates (ESI: 52%, no-ESI: 39%, p=0.15). For operative patients, crossover rates to non-operative treatment did not differ between ESI and no-ESI groups (ESI: 23%, no-ESI: 16%, p=0.38). CONCLUSIONS For surgical degenerative spondylolisthesis patients, there was no relationship between ESI and improved clinical outcomes over a 4-year study. For nonoperative patients, ESI was associated with inferior pain reduction through 3 years of follow-up; however, this was confounded by higher levels of baseline pain. ESI showed little relationship with surgical crossover. FDA DEVICE/DRUG STATUS Unavailable from authors at time of publication.

BACKGROUND CONTEXT As surgery is increasingly recommended for patients with neurologic deterioration secondary to central cord syndrome (CCS), it is important to investigate the relationship between time to surgery and patient outcomes. The merits of early vs delayed surgical treatment remain controversial in the literature. PURPOSE Investigate associations between time to surgical intervention and surgical outcomes for CCS patients STUDY DESIGN/SETTING Retrospective review of Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (NIS) PATIENT SAMPLE A total of 9,246 weighted inpatient discharges. OUTCOME MEASURES Complication rates, discharge destination, length of hospital stay (LOS). METHODS CCS patients (ICD-9 codes 952.03, 952.08, 952.13, 952.18) were isolated in the NIS database 2005-2013. Operative patients were grouped by time to intervention: same day as admission, 1-day delay, 2-day, 3-day, 4-7 days, 8-14 days, and >14 days. As appropriate, analysis of variance and chi-squared tests compared demographics, Charlson Comorbidity Index (CCI) scores, surgical details, LOS, discharge status, periop complications and total charges across patient groups. Controlling for age, CCI and concurrent traumatic fractures, binary logistic regression assessed surgical timing associated with increased odds of perioperative complication, using same-day patients as a reference group (odds ratio [95% confidence interval]). RESULTS Included: 6,734 CSS patients (59±16yrs, 26%F, mean CCI: 1.2±1.6). Overall rate of surgical treatment was 64.1%, with rates of surgery increasing from 2005 (50.0%) to 2013 (73.0%, p 14 days. Timing groups did not differ in trauma status at admission (shock or hemorrhage, p=0.261); however, age differed between groups (min: 1 day [58±15 years], max: >14 days [63±13 years], p 14 days to surgery had increased odds of periop cardiac (7.0 [1.6-30.0]) and infection (6.1 [2.2-16.3]) complications. All timing groups beyond 3 days showed increased odds of VTE: 4-7 days (3.0 [1.6-5.5]), 8-14 days (3.0 [1.4-6.3]), 14+ days (5.6 [2.3-13.6]). Same-day surgery was also associated with lower total hospital charges than delayed surgery ($87,741 vs $118,815-$272,901, p CONCLUSIONS Patients undergoing surgery for CCS on the same day as admission showed significantly lower odds of complication, hospital charges, and higher rates of discharge to home than patients that experienced a delay to operation. In contrast, patients delayed >14 days to surgery were associated with inferior outcomes, including increased odds of cardiac complication and infection. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Persistent lumbopelvic malalignment following ASD-corrective surgery may impair quality of life and result in persistent pathologic compensation in the lower extremities. Patient-specific age- and BMI-adjusted alignment targets have been proposed to improve alignment outcomes; however, it is unclear whether reaching these postop targets reduces rates of pelvic nonresponse following surgery. PURPOSE Assess the relationship between pelvic nonresponse to ASD-corrective surgery and persistent lower-extremity compensation. STUDY DESIGN/SETTING Single center retrospective review. PATIENT SAMPLE Fifty-eight ASD patients. OUTCOME MEASURES Sagittal alignment. METHODS Included: surgical ASD patients with full-spine X-ray imaging at pre- and early postop follow-up ( RESULTS Following propensity score matching, PNR (N=29) and PR (N=29) patients did not differ in age, sex, BMI or preop sagittal spinal alignment (all p>0.05); however, PNR patients presented with less knee flexion (9° vs 14°, p=0.043). Groups did not differ in levels fused (10.8 vs 10.8, p=0.974) or osteotomy (93% vs 92%, p=0.902). Postop, PNR patients had inferior lumbopelvic alignment in PT (30° vs 17°), PI-LL (17° vs 3°), and greater global malalignment for TPA (27° vs 15°, all p 0.05). For patients with severe preop SVA deformity, overcorrection relative to ideal postop PT targets was associated with lower rates of pelvic non-response (under: 12%, match: 18%, over: 71%, p CONCLUSIONS Pelvic nonresponders following ASD-corrective surgery had higher rates of persistent compensatory action in the lower extremities. Patients with severe preop PT deformity who were surgically overcorrected with respect to ideal PI-LL had lower rates of postop pelvic nonresponse, indicating that for severely malalignmed patients, existing alignment targets may need to be adjusted to optimize alignment outcomes. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT The Miller et al adult spinal deformity frailty index (ASD-FI) correlates with increased complication risk after surgery; however, its development was not rooted in clinical outcomes, and the 40 factors needed for its calculation limit the index's utility in a clinical setting. PURPOSE Develop a simplified, weighted frailty index for ASD patients. STUDY DESIGN/SETTING Retrospective review of prospective ASD database. PATIENT SAMPLE A total of 50 ASD patients. OUTCOME MEASURES Health-related quality of life questionnaires: Oswestry Disability Index (ODI), SRS-22r, pain catastrophizing scale, Numerif Rating Scale (NRS) for Leg Pain. METHODS ASD patients (scoliosis≥20°, SVA≥5cm, PT≥25°, or TK ≥60°) with baseline ASD-FI component factors. Component ASD-FI parameters contributing to overall ASD-FI score were assessed via Pearson correlation. Top significant, clinically relevant factors were regressed against ASD-FI score to generate the modified ASD-FI (mASD-FI). Factors comprising the mASD-FI were regressed against the incidence of medical complications; weights for mASD-FI factors were calculated from these regression coefficients via the beta/Sullivan method. Total mASD-FI score was calculated by summing weights of expressed parameters, resulting in a score ranging from 0 to 21. Linear regression correlated ASD-FI and mASD-FI scores, and previously published ASD-FI cutoffs were used to generate corresponding mASD-FI frailty cutoffs: not frail (NF, 12). Analysis of variance assessed the relationship between increasing frailty category and validated baseline measures of patient pain and disability. RESULTS Included: 50 ASD patients (52±20yrs, 78% female). All the following preoperative factors correlated with ASD-FI score (all p 30 kg/m2 (weight: 5), depression (weight: 5), difficulty climbing stairs (3), presence of >3 medical comorbidities (2), leg weakness (2), difficulty getting dressed (1), bladder incontinence (1), and patient-reported deterioration in health within the past year (1). These factors were used to calculate the overall population's mean mASD-FI score: 5.7±5.2. Combined, these factors comprising the mASD-FI showed a trend of predicting the incidence of medical complications (Nagelkerke R2=0.558, Cox & Snell R2=0.399, p=0.065). Overall patient breakdown by mASD-FI frailty category: NF (70%), frail (12%), SF (18%). Increasing frailty category was associated with significant impairments in validated measures of disability, including ODI score (NF: 23.4, frail: 45.0, SF: 49.3, p CONCLUSIONS This study modifies an existing ASD frailty index and proposes a weighted, shorter mASD-FI. The mASD-FI relies less on patient-reported variables, and weights component factors by their contribution to adverse outcomes. As increasing mASD-FI score is associated with inferior clinical measures of pain and disability, the mASD-FI may serve as a valuable tool for preoperative risk assessment. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT The Adult Spinal Deformity Frailty Index (ASD-FI), a validated modality for quantifying frailty, stratifies patients into categories not frail (NF), frail (F) and severely frail (SF). However, the cost of treating each frailty state is unknown. PURPOSE Investigate the cost utility of treating not frail versus frail or severely frail ASD patients. STUDY DESIGN/SETTING Retrospective review of a prospective single center adult spinal deformity database. PATIENT SAMPLE A total of 79 operative and non operative ASD patients ≥18 years old, with baseline and 2Y ASD-FI and Oswestry Disability Index (ODI) scores. OUTCOME MEASURES ODI, SF-6D, Cost per quality adjusted life years (QALY), Incremental Cost Effectiveness, Ratio (ICER). METHODS Inclusion criteria was surgical ASD (scoliosis≥20°, SVA≥5cm, PT≥25°, or thoracic kyphosis ≥60°) patients >18 years with available frailty and ODI data at BL and 2-years post op. Independent T-Tests assessed baseline radiographic differences in PT, PI-LL, and Schwab SVA modifier status between NF vs. F/SF patients. Utility data was calculated using the ODI converted to the SF-6D using published conversion methods. QALYs utilized a 3% discount rate to account for residual decline to life expectancy (78.7 years). Costs were calculated using the PearlDiver database. After accounting for complications, LOS, revisions, and death, cost per QALY at 2Y and life expectancy were calculated for NF, and F/SF patients. ICER was compared between non op and operative NF and F/SF patients at 2Y and life expectancy. RESULTS Seventy-nine ASD patients met inclusion criteria. Descriptive statistics for the cohort were: age 51.0±6.8, 76% women, BMI 26.7±6.8, 54% osteotomy, 54% decompression, and 11.6±4.2 average levels fused. At BL, there were 48 NF, 26 F, and 4 SF pts. The average BL frailty for NF pts was 0.13±0.08, 0.39±0.06 for F, and 0.59±0.08 for SF pts. There were no differences in PT, PI-LL, or severe SVA Schwab modifier grades between NF or F/SF pts (all p>0.05). At 2-year follow up, there was no difference in the average cost of ASD surgery, $91,068.98 for NF patients and $90,888.53 for F/SF pts (p>0.05). The cost per QALY was higher for NF pts at 2 years vs F/SF pts ($464,239.62 vs. $321,107.89, p CONCLUSIONS Frail and severely frail patients had lower cost per QALY compared to not frail patients at 3 years and life expectancy. In addition, when compared to a non operative cohort of ASD patients, frail and severely frail patients had lower ICER values. While these results support operative correction of frail and severely frail patients, it is important to note that these patients are often at worse baseline disability, which is closely related to frailty scores, and have more opportunity to improve postoperatively. In addition, there may be a threshold of frailty that is not operable due to the risk of severe complications that is not captured by this analysis. While future research should investigate economic outcomes at extended follow-up times, these findings support the cost effectiveness of ASD surgery at all frailty states. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT The Patient-Reported Outcomes Measurement Information System (PROMIS) is a comprehensive self-report measurement tool with patient functions, symptoms, behaviors, and mental health outcomes. Little work has been done correlating PROMIS physical health domain metrics with established adult spinal deformity (ASD) classifications such as SRS-Schwab. PURPOSE To correlate sagittal alignment components via the SRS-Schwab classification system with established PROMIS domains in a cohort of ASD patients. STUDY DESIGN/SETTING Retrospective review of a single-center stereoradiographic database. PATIENT SAMPLE A total of 41 ASD patients with complete baseline radiographic and PROMIS data. OUTCOME MEASURES PROMIS physical health domain metrics (Pain Intensity [PI], Physical Function [PF], Pain Interference [Interference]), SRS-Schwab modifiers (SVA, PI-LL, PT) METHODS Surgical ASD patients (SVA≥5cm, PT≥25° or TK ≥60°) ≥18 years old with available baseline (BL) radiographic and PROMIS data were isolated in the single-center comprehensive Spine Quality Database (Quality). Patients were classified according to SRS-Schwab deformity modifiers(0,+,++) for SVA, PI-LL and PT. Descriptives and univariate analyses compared population-weighted PROMIS scores for PI, PF and Interference across ASD deformity modifiers. Conditional Tree Analysis (CTA) with logistic regression sampling established cut-off points for PROMIS scores predicting severe malalignment (++) at BL compared to mild or moderate (0,+). RESULTS A total of 41 patients (58.95 yrs,75.6%F,29.1kg/m2) met inclusion criteria. BL SRS modifiers were as follows: SVA 51.2%, 2.4%, 46.3% (0,+,++); PI-LL 27.3%, 12.1%, 60.6%(0,+,++); PT 18.2%, 36.4%, 45.5% (0,+,++). Mean cohort PI score was 94.2±6.0, mean PF score 8.95±10.1, mean Inter score 57.84±5.46. PF and Interference differed significantly across low and high SVA groups, with low SVA having significantly higher PF (13.50 vs 3.68,p 0.05). Low PI-LL pts had significantly higher PF than pts with ++PI-LL (19.3 vs 4.15,p=0.001) and trended lower PI and Inter without significance. No significant differences in PI, PF or Inter were found across PT groups (all p>0.05). CTA found a PI score>98 or PF score 98) and PF ( 0.05). Pain Interference did not predict SRS metrics to a significant degree (all p>0.05). CONCLUSIONS Inferior PROMIS scores of pain intensity and physical function predicted increasingly severe SRS sagittal modifiers at baseline, specifically severe sagittal vertical axis and lumbopelvic mismatch. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Background: Lumbar discectomy and laminectomy in patients with intervertebral disc herniation (IDH) is common, with variable reported reoperation rates. Our study examined which baseline characteristics might be risk factors for reoperation and compared outcomes between patients who underwent reoperation and those who did not. Methods: We performed a retrospective subgroup analysis of patients from the IDH arm of the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. We analyzed baseline characteristics and outcomes of patients who underwent reoperation and those who did not with use of data collected from enrollment through eight-years of follow-up after surgery. Follow-up times were measured from the time of surgery, and baseline covariates were updated to the follow-up immediately preceding the time of surgery for outcomes analyses. Results: At eight years, the reoperation rate was 15% (691 no reoperation; 119 reoperation). Sixty-two percent of these patients underwent reoperation because of a recurrent disc herniation; 25%, because of a complication or other factor; and 11%, because of a new condition. The proportion of reoperations that were performed for a recurrent disc herniation ranged from 58% to 62% in the individual years. Older patients were less likely to have reoperation (p = 0.015), as were patients presenting with asymmetric motor weakness at baseline (p = 0.0003). Smoking, diabetes, obesity, Workers’ Compensation, and clinical depression were not associated with a greater risk of reoperation. Scores on the Short Form (SF)-36 for bodily pain and physical functioning, the Oswestry Disability Index (ODI), and the Sciatica Bothersomeness Index as well as satisfaction with symptoms had improved less at the time of follow-up in the reoperation group (p < 0.001). Conclusions: In patients who underwent surgery for IDH, the overall reoperation rate was 15% at the eight-year follow-up. Patients of older age and patients presenting with asymmetric motor weakness were less likely to undergo a reoperation. Less improvement in patient-reported outcomes was noted in the reoperation group. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Hospital length of stay (LOS), 30-day readmission rate, and other metrics are increasingly being used to evaluate quality of surgical care. The factors most relevant to cervical spondylotic myelopathy (CSM) are not yet established.To identify perioperative factors associated with extended LOS and 30-day readmission following elective surgery for CSM.Surgical CSM patients at institutions represented by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) during 2010-2012 were included. Patients with fracture, 9 or more levels fused, or cancer were excluded. Extended LOS was defined as 75th percentile of the cohort. Univariate analysis and multivariate logistic regression identified predictors for extended LOS, 30-day readmission, and reoperation. Linear regression modeling was used to evaluate variables.Three thousand fifty-seven surgical CSM cases were isolated. Age (odds ratio [OR], 1.496), diabetes (OR, 1.691), American Society of Anesthesiologists (ASA) class (OR, 2.081), posterior surgical approach (OR, 2.695), and operative time (OR, 1.008) were all positive predictors (P 0.05) for extended LOS (≥4 days). Thirty-two percent of the cohort (976 patients) had 30-day readmission data. Among these, 915 patients were not readmitted (93.8%), while 61 (6.2%) were readmitted. Diabetes (OR, 1.460) and ASA class (OR, 2.539) were significant positive predictors for hospital readmission. Age (OR, 0.918) was a negative predictor of re-operation in readmitted patients, and pulmonary comorbidities (OR, 4.584) were a positive predictor (P0.05).Patients with diabetes and higher ASA class were at increased risk for extended LOS and readmission within 30-days. Patients with increased operative time have greater risk for extended LOS. Preoperative pulmonary comorbidities increased reoperation risk, whereas increased age reduced the risk. Attention to these factors may benefit CSM patients.

The causes and epidemiology of traumatic cervical spine fracture have not been described with sufficient power or recency. Our goal is to describe demographics, incidence, cause, spinal cord injuries (SCIs), concurrent injuries, treatments, and complications of traumatic cervical spine fractures.A retrospective review was carried out of the Nationwide Inpatient Sample. International Classification of Disease, Ninth Revision E-codes identified trauma cases from 2005 to 2013. Patients with cervical fracture were isolated. Demographics, incidence, cause, fracture levels, concurrent injuries, surgical procedures, and complications were analyzed. t tests elucidated significance for continuous variables and χA total of 488,262 patients were isolated (age, 55.96 years; male, 60.0%; white, 77.5%). Incidence (2005, 4.1% vs. 2013, 5.4%), Charlson Comorbidity Index (2005, 0.6150 vs. 2013, 1.1178), and total charges (2005, $71,228.60 vs. 2013, $108,119.29) have increased since 2005, whereas length of stay decreased (2005, 9.22 vs. 2013, 7.86) (all P 0.05). The most common causes were motor vehicle accident (29.3%), falls (23.7%), and pedestrian accidents (15.7%). The most frequent fracture types were closed at C2 (32.0%) and C7 (20.9%). Concurrent injury rates have significantly increased since 2005 (2005, 62.3% vs. 2013, 67.6%). Common concurrent injuries included fractures to the rib/sternum/larynx/trachea (19.6%). Overall fusion rates have increased since 2005 (2005, 15.7% vs. 2013, 18.0%), whereas decompressions and halo insertion rates have decreased (all P0.05). SCIs have significantly decreased since 2005, except for upper cervical central cord syndrome. Complication rates have significantly increased since 2005 (2005, 31.6% vs. 2013, 36.2%). Common complications included anemia (7.7%), mortality (6.6%), and acute respiratory distress syndrome (6.6%).Incidence, complications, concurrent injuries, and fusions have increased since 2005. Length of stay, SCIs, decompressions, and halo insertions have decreased. Indicated trends should guide future research in management guidelines.

History of previous cervical spine surgery is a frequently cited cause of worse outcomes after cervical spine surgery. The purpose of this study was to determine any differences in clinical outcomes after cervical spine surgery between patients with and without a history of previous cervical spine surgery.A multicenter prospective database was reviewed retrospectively to identify patients with cervical spondylosis undergoing surgery with a minimum 2-year follow-up. Patients were divided into 2 groups: patients with (W) or without (WO) previous history of cervical spine surgery. Statistical analyses of Health-Related Quality of Life scores were analyzed with statistical software to fit linear mixed models for continuous longitudinal outcome.A total of 1286 patients (377 W, 909 WO) met criteria for inclusion. Overall, patients in both groups experienced an improvement in their Health-Related Quality of Life scores. However, patients in the W group had significantly decreased improvement compared with WO patients in the Neck Disability Index score and the following SF-36 domain scores: Role Physical, Bodily Pain, General Health, Vitality, Social Functioning, Health Transition, and Physical Component Summary at all time points (P0.05). There was no statistically significant difference between the W and WO groups in operative time, estimated blood loss, length of stay, or complications (P0.05).Patients with a history of previous cervical spine surgery had inferior improvement in quality of life outcome scores. Patients with a history of previous surgical intervention who elect to undergo subsequent surgeries should be appropriately counseled about expected results.

BACKGROUND CONTEXT Computer adaptive testing facilitates quicker administration of patient-relevant questions. The Patient Reported Outcome Measurement Information System (PROMIS) instruments of Physical Function, Pain Intensity and Pain Interference have been shown to correlate with established patient outcome metrics, though this relationship has yet to be investigated in relation to patient satisfaction. PURPOSE The aim of this study was to study the relationship between PROMIS and VAS scores and patient satisfaction in thoracolumbar patients. STUDY DESIGN/SETTING Retrospective review of single institution clinical data and patient-reported outcome measures. PATIENT SAMPLE A total of 208 spine patients with a thoracolumbar (TL) diagnosis. OUTCOME MEASURES ODI, Visual Analog Scale (VAS) for Back and Leg pain, Scoliosis Research Society 22 (SRS-22); Patient Reported Outcome Measurement Information System (PROMIS). METHODS Inclusion was patients greater than 18 years with a diagnosis related to the thoracolumbar spine (stenosis, disc herniation, low back pain, disc degeneration, spondylolysis most commonly). Bivariate correlations assessed the linear relationships of PROMIS scores (Physical Function, Pain Intensity, and Pain Interference) and ODI with VAS Leg and Back pain scores and patient satisfaction (SRS-22) questions specific to patient satisfaction of their back shape and back management. Linear regression predicted the relationship of PROMIS to VAS and satisfaction outcomes. Statistical significance was set at P RESULTS A total of 208 patients with a thoracolumbar diagnosis were included (age 58.39 ± 73.32 years, 49% female). VAS back pain scores (r=0.673, P CONCLUSIONS VAS Back Pain scores predicted PROMIS Pain Intensity scores as strongly as ODI, though ODI outperformed in predicting PROMIS Physical Function and Pain Interference. Conversely, PROMIS Pain Intensity predicted VAS Back Pain stronger than ODI, though ODI outperformed the other two PROMIS domains. Patients’ satisfaction of the shape of their back and their back management were significantly correlated with PROMIS scores in all three domains.

BACKGROUND CONTEXT Common indications for transforaminal lumbar interbody fusion (TLIF) include foraminal stenosis, degenerative disc disease and spondylolisthesis. Although minimally invasive surgical techniques (MIS) for TLIF have been shown to provide adequate postoperative sagittal alignment, it is unclear whether these procedures result in adequate reduction of canal compressive forces. PURPOSE Assess baseline to postoperative changes in cross-sectional canal area in patients undergoing minimally invasive transforaminal lumbar interbody fusion. STUDY DESIGN/SETTING Retrospective clinical review of a prospective surgeon-maintained MIS database. PATIENT SAMPLE A total of 16 patients undergoing MIS TLIF. OUTCOME MEASURES Spinal canal cross-sectional area, stenotic levels. METHODS Consecutive patients >18years undergoing transforaminal lumbar interbody fusion via minimally invasive surgical technique were included. Patients with preoperative lumbar MRIs and postoperative lumbar MRI or CT scans were assessed for spinal canal cross sectional area at operative interspace levels. Stenotic levels were defined as canal cross sectional area RESULTS Overall, 16 patients met inclusion criteria and underwent minimally invasive transforaminal lumbar interbody fusion. Mean patient age was 54.3±12.1years, 63% of patients were female, and mean Charlson Comorbidity Index score was 0.86±1.10. Patients presented with three primary diagnoses: herniated nucleus pulposis (36.8%), stenosis (42.1%) and spondylosis (21.1%). On average, patients underwent fusions spanning 1.69±1.13 levels, and 37.5% of patients underwent multilevel fusion. 93.7% of cases involved laminotomy, 31.3% laminectomy, 81.3% foraminotomy. Mean operative time was 349 minutes and blood loss was 389±486 ccs. From baseline to postoperative intervals, 87.5% of patients showed an increase in mean operative interspace canal cross sectional area, with the overall cohort showing significant improvement in canal cross sectional area (207.6 mm2 to 301.6 mm2, p CONCLUSIONS Following minimally invasive transforaminal lumbar interbody fusion, patients showed a significant increase in spinal canal cross sectional area. This increase in canal cross sectional area corresponded with an overall decrease in the rate of lumbar stenosis, suggesting MIS TLIF procedures have the potential to provide adequate relief of spinal canal compressive forces.

BACKGROUND CONTEXT Computer adaptive testing is becoming increasingly common in assessing patient outcomes. The Patient Reported Outcome Measurement Information System (PROMIS) instruments of Physical Function, Pain Intensity and Pain Interference have been shown to correlate with established patient outcome metrics, though this relationship has yet to be investigated for patients with thoracolumbar spinal pathologies. PURPOSE The aim of this study was to study the relationship between PROMIS and ODI scores in thoracolumbar patients. STUDY DESIGN/SETTING Retrospective review of single institution clinical data and patient-reported outcome measures. PATIENT SAMPLE A total of 208 spine patients with a thoracolumbar (TL) diagnosis. OUTCOME MEASURES Legacy metrics: Oswestry Disability Index (ODI), Patient Reported Outcome Measurement Information System (PROMIS). METHODS Inclusion was patients greater than 18 years of age with a diagnosis related to the thoracolumbar spine (most common diagnoses included spinal stenosis, disc herniation, low back pain, disc degeneration, spondylolysis). Bivariate correlations assessed the linear relationships between ODI and PROMIS scores (Physical Function, Pain Intensity, and Pain Interference). Correlation cutoffs were used to assess patients with high and low correlation between ODI and PROMIS domains. Linear regression predicted the relationship of ODI to PROMIS outcomes. Statistical significance was set at P RESULTS A total of 208 patients with a thoracolumbar diagnosis were included (age 58.39 ± 73.32 years, 49% female). ODI correlated with PROMIS Physical Function (r=−0.737, P CONCLUSIONS There is a large amount of variability in PROMIS scores that ODI cannot account for. Certain ODI questions, such as walking, social life, and lifting ability correlate strongly with PROMIS while ODI questions such as sitting, standing and sleeping do not correlate well with PROMIS. Further work is required to assess these discrepancies and tease out the factors contributing to these differences.