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Study Design: Case-control study., Objective: To introduce a classification system that will include the major types of degenerative changes and failures related to the proximal junction, and to determine the clinical course and characteristics for the different types of proximal junctional degeneration., Background: Proximal junctional kyphosis and failures are well recognized after adult spinal fusion; however, a standardized classification is lacking., Materials and Methods: The proposed system identified 4 different patterns of proximal junctional degeneration: (1) Type 1 (multilevel symmetrical collapse), (2) Type 2 (single adjacent level collapse), (3) Type 3 (fracture), and (4) Type 4 (spondylolisthesis). A single-center database was reviewed from 2018 to 2021. Patients 18 years or older of age, who underwent posterior spinal fusion of ≥3 levels with an upper instrumented vertebral level between T8 and L2, and a follow-up of ≥2 years were included. Radiographic measurements, revision surgery, and time to revision were the primary outcomes., Results: One hundred fifty patients were included with a mean age of 65.1 (±9.8) years and a mean follow-up of 3.2 (±1) years. Sixty-nine patients (46%) developed significant degenerative changes in the proximal junction and were classified accordingly. Twenty (13%) were type 1, 17 (11%) were type 2, 22 (15%) were type 3, and 10 (7%) were type 4. Type 3 had a significantly shorter time to revision with a mean of 0.9 (±0.9) years. Types 3 and 4 had greater preoperative sagittal vertical axis, and types 1 and 3 had greater final follow-up lumbar lordosis. Bone density measured by Hounsfield units showed lower measurements for type 3. Types 1 and 4 had lower rates of developing proximal junctional kyphosis. Type 1 had the lowest revision rate with 40% (types 2, 3, and 4 were 77%, 73%, and 80%, respectively, P = 0.045)., Conclusion: This novel classification system defines different modes of degeneration and failures at the proximal junction, and future studies with larger sample sizes are needed for validation., Level of Evidence: Level III., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Workflow for cortical bone trajectory (CBT) screws includes tapping line-to-line or under tapping by 1 mm. We describe a non-tapping, two-step workflow for CBT screw placement, and compare the safety profile and time savings to the Tap (three-step) workflow. Patients undergoing robotic assisted 1-3 level posterior fusion with CBT screws for degenerative conditions were identified and separated into either a No-Tap or Tap workflow. Number of total screws, screw-related complications, estimated blood loss, operative time, robotic time, and return to the operating room were collected and analyzed. There were 91 cases (458 screws) in the No-Tap and 88 cases (466 screws) in the Tap groups, with no difference in demographics, revision status, ASA grade, approach, number of levels fused or diagnosis between cohorts. Total robotic time was lower in the No-Tap (26.7 min) versus the Tap group (30.3 min, p = 0.053). There was no difference in the number of malpositioned screws identified intraoperatively (10 vs 6, p = 0.427), screws converted to freehand (3 vs 3, p = 0.699), or screws abandoned (3 vs 2, p = 1.000). No pedicle/pars fracture or fixation failure was seen in the No-Tap cohort and one in the Tap cohort (p = 1.00). No patients in either cohort were returned to OR for malpositioned screws. This study showed that the No-Tap screw insertion workflow for robot-assisted CBT reduces robotic time without increasing complications., (© 2024. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Study Design: Prospective observational cohort., Objectives: To examine the cost-effectiveness of IntraOperative ElectroMyeloGraphy (IO-EMG) by evaluating how often an abnormal IO-EMG signal changed the surgeon's surgical plan, or replaced a pedicle screw either intra-operatively or as a second unplanned surgery., Methods: Patients undergoing instrumented posterolateral lumbar fusion were monitored with intraoperative triggered EMG's. Pedicle screws were placed freehand from L1 to S1 by attending physicians and fellows. Concern for pedicle breach was a screw stimulation<10 mA., Results: There were 145 cases with a total of 725 pedicle screws placed. Mean age was 57.8 ± 14.2 yrs, OR time was 238 ± 95 minutes, EBL was 426.8 ± 354.3cc. Mean number of surgical levels fused was 2.7 ± 1.1. 686 (95%) screws stimulated at >10 mA and 39 (5%) screws stimulated at <10 mA. All 39 screws were removed and pedicles re-examined. Intraoperative screw repositioning was necessary in 8 of 145 cases (6%). No patient required a return to the OR for screw repositioning. As a worst case cost analysis, assuming the 8 patients requiring intraoperative screw positioning would have returned to the OR at a cost of $11,798 per readmission, the per patient cost is $651 which is less than the ION per patient cost of $750., Conclusions: Only 1% of the 725 lumbar pedicle screws placed in 8 of 145 cases required repositioning. Due to the infrequency of pedicle wall breaches and the cost of ION, the utility of this modality in straightforward lumbar fusions should be critically evaluated., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Controversy exists regarding the ability of posterior (transforaminal) lumbar interbody fusion (PLIF/TLIF) to achieve lordosis. We hypothesized that an interbody device (IBD) designed for positioning in the anterior disc space produces greater lordosis than IBDs designed for straight-in positioning. The purpose of this study is to determine if using either an anterior-position or straight-in position IBD design were associated with successful achievement of postoperative lordosis., Methods: A consecutive series of patients undergoing a undergoing a single-level, posterior open midline (transforaminal) lumbar interbody fusion procedure for degenerative spine conditions during a time period when the two types of interbody devices were being used at surgeon discretion were identified from a multi-surgeon academic training center. Patient demographics and radiographic measures including surgical level lordosis (SLL), anterior disc height, middle disc height, posterior disc height, IBD height, and IBD insertion depth were measured on preop, immediate postop, and one-year postop standing radiographs using PACS. Group comparison and regression analysis were performed using SPSS., Results: Sixty-one patients were included (n=37 anterior, n=34 straight-in). Mean age was 59.8±8.7 years, 32 (52%) were female. There was no difference between IBD type (anterior vs. straight-in) for mean Pre-op SLL (19±7° vs. 20±6°, p=0.7), Post-op SLL (21±5° vs 21±6°, p=0.5), or Change in SLL (2±4° vs. 1±5°, p=0.2). Regression analysis showed that Pre-op SLL was the only variable associated with Change in SLL (Beta = negative 0.48, p=0.000). While the mean Change in SLL could be considered clinically insignificant, there was wide variability: from a loss of 9° to a gain of 13°. Gain of lordosis >5° only occurred when Pre-op SLL was <21°, and loss of lordosis >5° only occurred when Pre-op SLL was >21°., Conclusions: While group averages showed an insignificant change in segmental lordosis following a posterior (transforaminal) interbody fusion regardless of interbody device type, pre-operative lordosis was correlated with a clinically significant change in segmental lordosis. Preoperative hypolordotic discs were more likely to gain significant lordosis, while preoperative hyperlordotic discs were more likely to lose significant lordosis. Surgeon awareness of this tendency can help guide surgical planning and technique., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Author(s).)

Background: With the current opioid crisis, as many as 38% of patients are still on opioids one year after elective spine surgery. Identifying drivers of in-hospital opioid consumption may decrease subsequent opioid dependence. We aimed to identify the drivers of in-hospital opioid consumption in patients undergoing 1-2-level instrumented lumbar fusions., Methods: This is a retrospective cohort study. Electronic medical record analysts identified consecutive patients undergoing 1-2 level instrumented lumbar fusions for degenerative lumbar conditions from 2016 to 2018 from a single-center hospital administrative database. Oral, intravenous, and transdermal opioid dose administrations were converted to morphine milligram equivalents (MME). Linear regression analysis was used to determine associations between postoperative day (POD) 4 cumulative in-hospital MMEs and the patients' baseline characteristics including body mass index (BMI), race, American Society of Anesthesiologists (ASA) grade, smoking status, marital status, insurance type, zip code, number of fused levels, approach and preoperative opioid use., Results: A total of 1,502 patients were included. The mean cumulative MMEs at POD 4 was 251.5. Linear regression analysis yielded four drivers including younger age, preoperative opioid use, current smokers and more levels fused. There were no associations with surgical approach, zip code, ASA grade, marital status, BMI, race or insurance type., Conclusions: Use of preoperative opioids and smoking are modifiable risk factors for higher in-hospital opioid consumption and can be targets for intervention prior to surgery in order to decrease in-hospital opioid use., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jss-20-626). The authors have no conflicts of interest to declare., (2021 Journal of Spine Surgery. All rights reserved.)

Background: The opioid epidemic is at epic proportions currently in the United States. Exposure to opioids for surgery and subsequent postoperative pain management is a known risk factor for opioid dependence. In addition, opioids can have a negative impact on multiple aspects including clinical outcomes, length of hospital stay, and overall cost of care. Thus, the greatest effort to reduce perioperative opioid use is necessary and a multimodal pain control (MMPC) has been gaining popularity. However, its efficacy in spine surgery is not well known. We aimed to evaluate the efficacy of a MMPC protocol in patients undergoing lumbar single-level anterior lumbar interbody fusion (ALIF)., Methods: This is a retrospective comparative study. From a prospective, single-surgeon, surgical database, consecutive patients undergoing single-level ALIF with or without subsequent posterior fusion for degenerative lumbar conditions were identified before and after initiation of the MMPC protocol. The MMPC protocol consisted of a preoperative oral regimen of cyclobenzaprine (10 mg), gabapentin (600 mg), acetaminophen (1 g), and methadone (10 mg). Postoperatively they received a bilateral transverse abdominis plane block with 0.5% Ropivacaine prior to extubation. We compared in-hospital opioid consumption between the MMPC and non-MMPC cohorts as well as baseline demographic, the length of hospital stay, cost, and rate of postoperative ileus. Opioid consumption was calculated and normalized to the morphine milligram equivalents (MMEs)., Results: In total, 68 patients in the MMPC cohort and 39 in the non-MMPC cohort were identified. There was no difference in baseline demographics including sex, body mass index, smoking status, or preoperative opioid use between the two groups. Although there was no difference in the MMEs on the day of surgery (58.5 vs. 66.9, P=0.387), cumulative MMEs each day after surgery was significantly lower in the MMPC cohort, with final cumulative MMEs being reduced by 62% (120.2 vs. 314.8, P<0.001). There was no difference in postoperative ileus, length of stay, and hospital costs., Conclusions: The use of a MMPC protocol in patients undergoing single-level ALIF for degenerative conditions reduced opioid consumption starting on the first day after surgery, resulting in a cumulative reduction of 62%., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jss-20-629). Dr. JLG reports personal fees from Acuity, personal fees from Medtronic, personal fees from DePuy, personal fees from Alphatec, from Stryker, from Acuity, from K2M, from NuVasive, personal fees from Pfizer, outside the submitted work; Dr. CHC 3rd reports personal fees from Alphatec, personal fees from Medtronic, personal fees from NuVasive, personal fees from Alphatec, personal fees from Medtronic, personal fees from Titan, personal fees from SRS Committee, personal fees from NASS Committee, outside the submitted work; Dr. MD reports personal fees from Medtronic, personal fees from NuVasive, outside the submitted work; Dr. RKO 2nd reports personal fees from Medtronic, personal fees from NuVasive, grants from Pfizer, grants from Texas Scottish Rite Hospital, grants from Alan L. & Jacqueline B. Stuart Spine Research, grants from Cerapedics, grants from SRS, grants from Medtronic, grants from OREF, grants from ISSG, outside the submitted work; Dr. JRD 2nd reports personal fees from Medtronic, personal fees from DePuy, other from Federation Of Spine Association, other from SRS, personal fees from Pfizer, outside the submitted work; Dr. SDG reports personal fees from Medtronic, outside the submitted work; Dr. LYC reports personal fees from AO spine, personal fees from Center for Spine Surgery and Research of the University of Southern Denmark, personal fees from University of Louisville Institutional Review Board, grants from Scoliosis Research Society Research, grants from Orthopedic Educational Research Fund, grants from Integra, grants from Pfizer, personal fees from Pfizer, outside the submitted work. The other authors have no conflicts of interest to declare., (2020 Journal of Spine Surgery. All rights reserved.)

Objective: Posterior interbody fusion is commonly performed for degenerative lumbar conditions. A minimally invasive technique of midline exposure limited only to the facets and fixation with laterally directed cortical bone trajectory (CBT) screws was introduced with the intent of decreasing surgical morbidity. The purpose of this study was to determine if posterior interbody fusion with this limited midline exposure will have less blood loss and shorter operative times (i.e., can be considered minimally invasive) compared to traditional open transforaminal interbody fusion., Methods: A consecutive single-surgeon series of patients who underwent posterior interbody fusion with either a navigated, midline only exposure (MidLIF) or full, traditional open, exposure of the transverse processes with a posterolateral fusion (open TLIF) were identified. Demographic, peri-operative data, patient reported outcomes (PROs), and reoperation/readmission rates were collected and compared., Results: There were 29 cases in the MidLIF and 27 in the open TLIF group. Both groups were similar with respect to surgical indications, age, BMI, gender, ASA grade and operative level. The MidLIF group had significantly lower estimated blood loss (266 vs. 446 cc, p = 0.003), shorter operative time (170 vs. 210 minutes, p = 0.003), and shorter length of hospital stay (2.9 vs. 3.7 days, p = 0.016) compared to the open TLIF group. A sub-analysis of single-level cases showed similar findings with significantly lower estimated blood loss (247 vs. 411 cc, p = 0.10), shorter operative time (159 vs. 199 min, p = 0.003), and shorter length of hospital stay (2.9 vs. 3.7 days, p = 0.023) in the MidLIF group. Patient reported outcomes at 6 weeks, 3 months, 6 months, 12 months and 24 months post-operative favored MidLIF with significantly greater ODI improvements at both 6 weeks and 12 months; and lower ODI and back pain at both 12 months and 24 months., Conclusions: MidLIF had lower blood loss and shorter operative time compared to the traditional open TLIF technique. These differences compare well to reported values in the literature for tubular minimally-invasive TLIF. Patient reported outcomes from 6 weeks to 24 months post-operative, hospital length of stay, and reoperation/readmission rates all favored MidLIF compared to traditional open TLIF.

Background Context: Previous studies suggest that a postoperative symptom state with Oswestry Disability Index (ODI)≤20 and pain Numeric Rating Scales (NRS)≤2 following surgery for lumbar degenerative conditions are reasonable thresholds for best outcomes in which patients will be unlikely to seek additional medical care or require additional health-care resources., Purpose: To identify prognostic factors that predict a "best outcome," defined as postoperative ODI≤20 and pain NRS≤2 following fusion for lumbar degenerative conditions., Study Design: Longitudinal observational cohort., Patient Sample: A total of 396 patients from a single site enrolled in the Quality Outcomes Database who underwent fusion for lumbar degenerative conditions., Outcome Measures: Oswestry Disability Index, Back and Leg Pain NRS (0-10)., Methods: Collected and analyzed variables included age, sex, body mass index, American Society of Anesthesia grade, number of surgical levels, surgical time, preoperative ODI, preoperative back pain, preoperative leg pain, workmen compensation status, surgical approach, smoking status, and principal diagnosis., Results: A total of 74 patients (19%) reported a minimal symptom state at 1-year postoperative (ODI≤20, back pain NRS≤2, and leg pain NRS≤2) and were included in the best outcomes group. Patients in the best outcomes group were older (62 vs. 57 years, p=.001), had lower preoperative ODI (43 vs. 56, p=.000), lower preoperative back pain (6.5 vs. 7.5, p=.000). They had fewer surgical levels (1.25 vs. 1.47, p=.005) and shorter operative times [OR] times (208 vs. 241 minutes, p=.002). They were more likely to have a preoperative diagnosis of spondylolisthesis or disc herniation and less likely to have a diagnosis of adjacent segment disease or mechanical disc collapse (p=.001). Stepwise forward regression analysis revealed diagnosis (p=.023, OR=0.75), age (p=.000, OR=1.04), baseline ODI (p=.000, OR=0.96), and number of levels (p=.019, OR=0.53) as predictive variables., Conclusion: Achieving a minimal symptom state, defined here as a postoperative ODI≤20 and pain NRS≤2, following fusion for lumbar degenerative conditions is more likely in an older patient with a lower baseline ODI undergoing a single level lumbar fusion for spondylolisthesis., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background Context: Transforaminal lumbar interbody fusion (TLIF) and dual-approach anteroposterior (AP) are common techniques to achieve circumferential fusion for lumbar spondylolisthesis. It is unclear which approach is more cost-effective., Purpose: Our goal was to determine the incremental cost-effectiveness ratio (ICER) by calculating the cost per quality-adjusted life year (QALY) for each approach., Study Design/setting: This study is a propensity-matched cost-effectiveness comparison., Patient Sample: Patients with lumbar spondylolisthesis undergoing single-level AP fusion or TLIF and enrolled in a prospective observational surgical database were included in this study., Outcome Measures: The outcome measures in this study were the Oswestry Disability Index (ODI) and the Short Form-6D (SF-6D)., Methods: From a prospective surgical database, patients with lumbar spondylolisthesis undergoing single-level AP fusion were propensity matched to a TLIF cohort based on age, gender, body mass index, smoking status, workers compensation, preoperative ODI, and back and leg pain numeric scores. Quality-adjusted life years gained were determined using baseline and 1- and 2-yearpostoperative SF-6D scores. Cost was calculated from actual, direct hospital costs and included subsequent postsurgical costs (epidural spinal injections, spine-related emergency department visits, readmissions, and revision surgery)., Results: Thirty-one cases of AP fusions were identified and propensity matched to 31 TLIF patients. Patients undergoing TLIF had a shorter mean operative time (270 vs. 328 minutes, p=.039) but no difference in estimated blood loss (526 vs. 548 cc, p=.804) or hospital length of stay (4.5 vs. 6.1 days, p=.146). Quality-adjusted life years gained at 2 years were also similar (0.140 vs. 0.130, p=.672). The mean index surgery and the total 2-year costs were lower for TLIF compared with AP (index: $29,428 vs. $31,466; final: $30,684 vs. $331,880). As overall costs were lower and QALYs gained were similar for TLIF compared with AP fusion, TLIF was the dominant intervention with an ICER of $116,327., Conclusions: Under our study parameters, surgical treatment of lumbar spondylolisthesis with TLIF is more cost-effective compared with AP fusion. Because of the short-term follow-up, the longevity of this should be further investigated., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background Context: Although lumbar disc herniation (LDH) classically presents with lower extremity radiculopathy, there are patients who have substantial associated back pain., Purpose: The present study aims to determine if patients with LDH with substantial back pain improve with decompression alone., Study Design: This is a longitudinal observational cohort study., Patient Sample: Patients enrolled in the Quality and Outcomes Database with LDH and a baseline back pain score of ≥5 of 10 who underwent single- or two-level lumbar discectomy only., Outcome Measures: Back and leg pain scores (0-10), Oswestry Disability Index (ODI), and EuroQoL 5D were measured., Methods: Standard demographic and surgical variables were collected, as well as patient-reported outcomes at baseline and at 3 and 12 months postoperatively., Results: The mean age of the cohort was 49.8 years and 1,195 (52.8%) were male. Mean body mass index was 30.1 kg/m 2 . About half of the patients (1,103, 48.8%) underwent single-level discectomy and the other half (1,159, 51.2%) had two-level discectomy. Average blood loss was 44 cc. Most of the patients (2,217, 98%) were discharged home with routine postoperative care. The average length of stay was 0.53 days. At 3 and 12 months postoperatively, there were statistically significant (p<.000) improvements in back pain (from 7.7 to 2.9 to 3.2), leg pain (from 7.5 to 2.3 to 2.5), and ODI (from 26.2 to 11.6 to 11.2). Patients with a single-level discectomy, compared with patients with a two-level discectomy, had similar improvements in 3- and 12-month back pain, leg pain, and ODI scores., Conclusions: Patients with LDH who have substantial back pain can be counseled to expect improvement in their back pain scores 12 months after a discectomy., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Anterior cervical discectomy and fusion (ACDF) for cervical degenerative disease is an accepted treatment for symptomatic cervical radiculopathy and myelopathy. One- and two-level fusions are much more common and more widely studied. Outcomes and revision rates for three- and four-level ACDF have not been well described. The purpose of this study is to report on clinical outcomes and revision rates following multilevel ACDF., Methods: Patients who underwent three- or four-level anterior cervical discectomy with plate fixation between 2006 and 2011 from a single-center multi-surgeon practice for symptomatic cervical degenerative disease were identified. Improvements in neck disability index (NDI), neck and arm pain scores two years after surgery and revision rates were analyzed., Results: Forty-six patients with a mean age of 55.9 years were included in the analysis. Twenty-one (46%) were male, 10 (22%) were smokers. Forty-one (89%) underwent three-level fusion and 5 (11%) underwent four-level fusion. NDI improved from 34.46 at baseline to 25.47 at 2 years. Neck pain improved from 7.04 at baseline to 3.95 and arm pain improved from 6.24 to 3.09 at 2 year follow up. Sixteen patients (35%) returned to surgery within 2 years with 11 of these patients (24%) returning for non-union. The average number of days to revision surgery was 750.6±570.3 days., Conclusions: Patients undergoing three- and four-level ACDF for multilevel cervical disease demonstrate substantial improvement in outcomes. However, the two-year revision rate is relatively high at 35% with the majority of these patients returning due to non-union., Competing Interests: Conflicts of Interest: Dr. JL Laratta reports consulting for Evolution Spine and research support from Orthopaedic Science Research Foundation and Norton Healthcare. Dr. LY Carreon reports consulting for AO Spine, trips/travel for Center for Spine Surgery and Research of the University of Southern Denmark and University of Louisville Institutional Review Board, and research support from the Scoliosis Research Society, Orthopedic Educational Research Fund, Integra and Pfizer. Dr. R. Kirk Owens reports consulting for Medtronic, Nuvasive and Alphatec, trips/travel from Depuy Synthes, Medtronic, and Nuvasive, research support from Pfizer and Integra, and fellowship support from Norton Healthcare. The other authors have no conflicts of interest to declare.

Study Design  Retrospective comparative cohort. Objective  Pseudarthrosis following fusion for degenerative lumbar spine pathologies remains a substantial problem. Current data shows that patients who develop a pseudarthrosis have suboptimal outcomes. This study evaluates if treatment of pseudarthrosis can be affected by surgical approach. Methods  Medical records of 63 female and 65 male patients (mean age 50.37) who were treated for nonunion following lumbar fusion were reviewed. Sixty patients underwent posterolateral fusion (PSF), 18 underwent PSF with transforaminal interbody fusion (TLIF), 32 underwent anterior and posterior spinal fusion (AP), and 24 underwent anterior lumbar interbody fusion (ALIF). Results  Significant differences between the treatment groups were observed in length of stay ( p  = 0.000), blood loss ( p  = 0.000), and operative time ( p  = 0.000). In the AP fusion group, minimal clinically important difference (MCID) was reached in 47% of patients for back pain, 28% for leg pain, and 28% for Oswestry Disability Index (ODI). PSF had the highest percentage of patients reaching MCID for Short Form-36 (SF-36) physical composite score at 25%. ALIF and TLIF subgroups reached MCID for ODI in 17% of patients. Linear regression analysis showed that type of surgical approach did not impact change in ODI scores. Conclusion  Although not statistically significant, the AP fusion group reached MCID more frequently in all outcomes except SF-36 Physical Component Summary. All surgical approaches examined for treatment of lumbar pseudarthrosis resulted in only poor to modest improvement in ODI. This result further emphasizes the importance of achieving a solid fusion with the index surgery.

Background Context: Obesity is a growing problem in health care. Studies have demonstrated similar functional outcomes but higher complication rates after spine surgery in obese patients., Purpose: This study aimed to compare patient-reported outcomes and revision rates 5 years after instrumented posterior lumbar fusion between normal, overweight, and obese patients., Study Design: Propensity matched case control., Patient Sample: Patients who had posterior instrumented lumbar spinal fusion from 2001 to 2008 from a single spine specialty center with complete preoperative and 5-year postoperative outcome measures were identified., Outcome Measures: Oswestry Disability Index (ODI), Back Pain (0-10) and Leg Pain (0-10) Numeric Rating Scales, and Short Form-36 Physical Composite Summary Scores (SF-36 PCS)., Methods: Three comparison groups, one with body mass index (BMI) ≥20-25 kg/m 2 (normal), another with ≥25-<30 kg/m 2 (overweight), and another with ≥30-40 kg/m 2 (obese) were created using propensity matching techniques based on demographics, baseline clinical outcome measures, and surgical characteristics. Five-year postoperative outcome measures and revision rates in the three groups were compared. One-way analysis of variance was used to compare continuous variables, and Fisher exact test was used to compare categorical variables between the groups. Significance was set at p<.01., Results: There were 82 cases matched in each cohort. Estimated blood loss (440 cc vs. 702 cc vs. 798 cc, p=.000) and operative time (234 minutes vs. 263 minutes vs. 275 minutes, p=.003) were significantly greater in the overweight and obese patients. Improvements in ODI (14.2 vs. 9.6 vs. 10.4, p=.226), SF-36 PCS (5.9 vs. 2.9 vs. 3.5, p=.361), back pain (3.0 vs. 2.0 vs. 2.1, p=.028), and leg pain (3.0 vs. 2.3 vs. 2.3, p=.311) scores were similar among the groups. Revision rates (14 vs. 15 vs. 13, p=.917), and time between index and revision surgery (p=.990) were similar among the three groups as well., Conclusion: When considering a subset of patient-reported outcomes and revision surgery after 5 years, patients with an elevated BMI >25 at baseline did not appear to have worse outcomes than those with a normal BMI of 20-25 when undergoing posterior lumbar fusion surgery. Obesity should not be considered a contraindication to surgery in patients with appropriate surgical indications., (Copyright © 2016 Elsevier Inc. All rights reserved.)

OBJECTIVE Studies have shown that anxious or depressed patients may have poorer outcomes after lumbar fusion. These conclusions were drawn from questionnaires specifically designed to measure anxiety and depression. The objective of this study is to determine if responses to the EQ-5D anxiety/depression domain or the items used to calculate the 36-Item Short-Form Health Survey (SF-36) Mental Component Summary (MCS) can predict outcomes after lumbar fusion surgery. METHODS Patients enrolled in the National Neurosurgery Quality and Outcomes Database from a single center with 1-year follow-up were identified. The outcomes collected include the Oswestry Disability Index (ODI), EQ-5D, SF-36, and the back- and leg-pain numeric rating scales (range 0-10). Linear regression modeling was performed to predict the 1-year ODI scores using the EQ-5D anxiety/depression domain and the 14 items used to calculate SF-36 MCS. RESULTS Complete data were available for 312 (88%) of 353 eligible patients. The mean patient age was 58.5 years, 175 (56%) patients were women, and 52 patients were smokers. After controlling for other factors, the item in the SF-36 that asks "Have you felt downhearted and depressed?" is the strongest predictor of the 1-year ODI score (r(2) = 0.191; p = 0.000) and 1-year EQ-5D score (r(2) = 0.205; p = 0.000). Neither the EQ-5D anxiety/depression domain nor the diagnoses of anxiety or depression were predictors of 1-year outcomes. CONCLUSIONS Patient responses to SF-36 item "Have you felt downhearted and depressed?" account for 20% of the variability of the 1-year ODI and EQ-5D scores and can be used by clinicians to screen for anxiety or depression in patients prior to lumbar fusion surgery. Clinicians may offer psychological support to these patients preoperatively in order to improve treatment outcomes.

Study Design: Case-matched retrospective., Objectives: The purpose of this study is to compare 2-year health-related quality of life (HRQOL) outcomes of patients who underwent 1-level or 2-level posterolateral spine fusion (PSF) versus transforaminal interbody fusion (TLIF) for degenerative spondylolisthesis, disk pathology, and postdecompression instability., Summary of Background Data: The optimal surgical technique for patients with spondylolisthesis or other degenerative conditions has not been defined. Historically, PSF was the most common procedure, whereas in recent years TLIF has gained popularity. Although theoretical advantages for TLIF have been outlined, evidence for improved outcomes with the addition of interbody support is limited., Methods: Patients with degenerative spondylolisthesis, with disk pathology and or postdecompression instability who underwent 1-level or 2-level TLIF and completed 2 years postoperative HRQOL measures were identified from a prospective database. These patients were then propensity-matched to a cohort of PSF patients based on age, number of surgical levels, body mass index, sex, smoking status, workers' compensation status, and preoperative outcome measures including the Oswestry Disability Index, SF-36 Physical Component Summary score, SF-36 Mental Composite Summary score, and back and leg pain scores. This produced 63 matched pairs with degenerative spondylolisthesis, 46 with disk pathology and 32 with postdecompression instability., Results: All patients in both groups for each cohort reported statistically significant improvement in HRQOL scores at 2 years postoperatively compared with baseline. Improvements in the Oswestry Disability Index, SF-36 Physical Component Summary score, and back and leg pain scores within the spondylolisthesis and disk pathology subgroups were similar between patients who had a TLIF compared with those who had a PSF. The postdecompression instability subgroup was the only subgroup in which TLIF outperformed PSF for every outcome measure., Conclusions: Clinical outcome was not significantly altered with TLIF as compared with PSF in patients with spondylolisthesis or disk pathology. However, TLIF resulted in better outcomes at 2 years postoperatively in patients with postdecompression instability.

Pediatric atlantoaxial rotatory subluxation (AARS) is a rare finding with various etiologies and treatment recommendations. Etiologies include both traumatic and nontraumatic causes. The diagnosis is suggested by clinical presentation and confirmed with imaging. Various forms of management have been discussed in the literature. However, no overall consensus has been established. We present 2 pediatric cases showing delayed spontaneous reduction of traumatic AARS. Images from computed tomography (CT) were used for initial diagnosis and to track management progression. Although the subluxation persisted on the 1-month follow-up CT in Case 1, the final CT images in both cases showed spontaneous reduction with anatomic positioning of C1 and C2. These cases demonstrate that delayed spontaneous reduction of traumatic pediatric AARS is possible with conservative treatment. Active reduction via traction may not be necessary. In the absence of compelling surgical indications to the contrary, a conservative approach to management of traumatic pediatric AARS is warranted.

Object: Recent studies have reported the incidence of superior facet joint violation using percutaneous techniques. These techniques have not been compared with the open midline approach. An increased incidence of superior facet violation may lead to adjacent-segment disease. In this paper, the authors' goal is to compare the rate of superior facet violation with the use of percutaneously placed pedicle screws versus midline approach open placement., Methods: Patients who underwent a single-level fusion using a percutaneous approach from L-1 to S-1 who had undergone CT scanning within 1 year after surgery were identified. A cohort who underwent open fusion matched by level of surgery was identified. All CT scans were reviewed by 3 fellowship-trained spine surgeons to determine the degree of facet violation. The final categorization for each screw was based on the most frequent reading among the 6 evaluations. The Fisher test was used to determine the association of facet violation with approach., Results: There were 66 patients in each group. Patients in the Percutaneous group were younger (mean 42.5 years) than those in the Open group (mean 57.8 years, p = 0.000). There was no statistically significant difference in sex distribution, surgical levels fused, or time between surgery and CT scan between the groups. Thirty-six (13.6%) of 264 screws in the percutaneous and 16 (6%) of 263 screws in the Open group were in the facet joint (p = 0.005). Of these, 17 (12%) of the 132 proximal screws in the percutaneous and 7 (5%) of the 131 proximal screws in the Open group were in the facet joint (p = 0.052)., Conclusions: The use of a percutaneous method to insert pedicle screws results in a statistically significantly higher incidence of facet joint violation, even if only proximal screws are considered. Further studies are needed to determine if this leads to a higher incidence of symptomatic adjacent-level disease.

Study Design: Retrospective review., Objective: To identify risk factors for cell saver transfusion in lumbar spinal surgery and determine if cell saver transfusions affected intraoperative or postoperative transfusion rates., Summary of Background Data: Cell saver has been used to minimize allogeneic blood transfusion in lumbar spinal surgery. Conflicting reports exist, which call into question the efficacy of cell saver use., Methods: We reviewed medical records of randomly selected patients who underwent posterolateral fusion with or without transforaminal interbody fusion from July 2010 to June 2011. Transfusion rates and transfusion-related complications were determined. Binary logistic regression was performed to identify risk factors for use of autologous cell saver transfusion., Results: There were 178 females and 107 males, with a mean age of 57.2 years. Of the 285 cases, 39 had no cell saver available, 147 had cell saver available but no autologous blood was recovered or transfused and 99 had an autologous cell saver transfusion. Patients who had cell saver transfusion had a higher rate of intraoperative allogeneic blood transfusion (52%) compared with those who did not (22%). There was no significant difference in the rate of postoperative transfusions or transfusion-related reactions between patients who did and did not have cell saver transfusion. Patient's age, smoking status, American Society of Anesthesiologists grade, use of anticoagulants preoperatively, primary or revision surgery, iliac crest bone graft harvest, anesthesiologist, or surgeon had no significant effect on cell saver infusion. Body mass index (odds ratio [OR] = 1.06), number of posterolateral fusion levels fused (OR = 2.50), and number of transforaminal interbody fusions performed (OR = 2.41) were independent risk factors for the use of autologous cell saver transfusion., Conclusion: Body mass index, multi-level fusion and transforaminal interbody fusion result in increased use of autologous cell saver transfusion in lumbar spinal surgery. Use of autologous cell saver transfusion did not reduce the requirement for intraoperative or postoperative allogeneic blood transfusion., Level of Evidence: 2.