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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.

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 Accounting for less than 0.4% of disc herniations, intradural lumbar disc herniations (ILDHs) are a rare occurrence primarily described as a complication after lumbar spine surgery. It is speculated that the herniation may propagate intradurally from either an unrecognized dural defect after initial surgery or as a result of adhesions between the dura and posterior longitudinal ligament. This report explores the etiology, presentation, diagnostic evaluation, and treatment of ILDH along with a case report and microsurgery video. OBSERVATIONS A 67-year-old patient who 1 year earlier had undergone an L2–5 laminectomy and L2–3 decompression with no known complications presented with low back pain and radiating right leg, buttock, and groin pain for 1 month. Physical examination indicated no numbness or weakness. Magnetic resonance imaging demonstrated a large ILDH. A transforaminal interbody fusion was performed followed by a durotomy, ILDH removal, and dural closure. A ventral dural defect was found and repaired during the procedure. LESSONS The treatment for ILDH is laminectomy with dorsal durotomy. Because ILDH has rarely been described in literature, understanding its presentation is crucial for prompt identification and management.

Severely injured patients are beleaguered by complications during convalescence, such as dysregulated biomineralization. Paradoxically, severely injured patients experience the loss of bone (osteoporosis), resulting in diminished skeletal integrity and increased risk of fragility fractures; yet they also accrue mineralization in soft tissues, resulting in complications such as heterotopic ossification (HO). The pathophysiology leading to dysregulated biomineralization in severely injured patients is not well defined. It has been postulated that these pathologies are linked, such that mineralization is “transferred” from the bone to soft tissue compartments. The goal of this study was to determine if severe injury-induced osteoporosis and soft tissue calcification are temporally coincident following injury. Using a murine model of combined burn and skeletal muscle injury to model severe injury, it was determined that mice developed significant progressive bone loss, detectable as early as 3 days post injury, and marked soft tissue mineralization by 7 days after injury. The observed temporal concordance between the development of severe injury-induced osteoporosis and soft tissue mineralization indicates the plausibility that these complications share a common pathophysiology, though further experiments are required., Highlights • Severely injured patients can experience both the loss of bone or the accrual of mineralization in soft tissues following injury. • It has been postulated that these pathologies are linked, such that mineralization is “transferred” between compartments. • In a murine model, we observed a temporal concordance between severe injury-induced osteoporosis and soft tissue mineralization. • These results support the plausibility that these complications share a common pathophysiology.

Hypothesis The aim of this meta-analysis was to compare the safety, efficacy, and opioid-sparing effect of liposomal bupivacaine (LB) vs. nonliposomal local anesthetic agents (NLAs) for postoperative analgesia after shoulder surgery. Methods A systematic literature review of randomized controlled clinical studies comparing the efficacy of LB with NLAs in shoulder surgery was conducted. Seven level I and II studies were included in the meta-analysis, and shoulder surgical procedures included arthroscopic rotator cuff repair and shoulder arthroplasty. Bias was assessed using The Cochrane Collaboration's tool. The primary outcome measures were visual analog scale pain scores and opioid consumption 24 and 48 hours after shoulder surgery. Subgroup analysis was performed for the method of LB administration (interscalene nerve block vs. local infiltration). Results A total of 7 studies (535 patients) were included in the final meta-analysis comparing LB (n = 260) with NLAs (n = 275). No significant difference was found between the LB and NLA groups in terms of visual analog scale pain scores at 24 hours (95% confidence interval, –1.02 to 0.84; P = .86) and 48 hours (95% confidence interval, –0.53 to 0.71; P = .78). Both groups had comparable opioid consumption at both 24 hours (P = .43) and 48 hours (P = .78) postoperatively and with respect to length of stay (P = .87) and adverse events (P = .97). Subgroup analysis demonstrated comparable efficacy irrespective of the method of administration of LB. Conclusion LB is comparable to NLAs with respect to pain relief, the opioid-sparing effect, and adverse effects in the first 48 hours after arthroscopic rotator cuff repair and total shoulder arthroplasty.

BACKGROUND CONTEXT Thoracolumbar malalignment is often seen in patients presenting with cervical deformities. For operative cervical deformity (CD) patients, it is unknown when the thoracic spine should be included in the construct. PURPOSE To investigate the CD patients in whom fusion to the thoracic spine was warranted. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE A total of 72 CD patients. OUTCOME MEASURES Radiographic parameters; complications, distal junctional kyphosis [DJK], reoperation; Health-Related Quality-of-Life [HRQLs]: NDI, NRS-neck, mJOA. METHODS Included: operative CD patients (C2-C7 lordosis 35°, segmental cervical kyphosis >15° across any 3 vertebra between C2-T1, C2-C7 SVA >4cm, McGregor's slope >20°, or CBVA > 25°) with baseline (BL) and up to 2-year (2Y) data. Patients with UIV at or above C4 and LIV extending beyond C7 into the thoracic spine were isolated (CT fusions). CT fusion patients were further stratified to upper and lower thoracic LIVs: T1-T4 [Short Fusion], beyond T4 [Long Fusion]. CT fusion patients were identified as having an optimal outcome at 2-year postop if they 1) did not have DJF and 2) had Virk et al. good clinical outcome [≥2 of the following: NDI RESULTS Seventy-two cervical deformity patients with CT fusion included (60.3±9.0years, 60% F, 29.4±7.6 kg/m2, levels fused: 7.8±3.2). By approach, 61% posterior-only and 39% combined. Fifty-nine patients (82%) had CT fusions with LIV of T4 or above, while 13 patients (18%) had fusions extending below T4. Thirty-two patients (44.4%) met the optimal outcome criteria, with no difference by fusion length (p=0.171). Eight patients qualified as long fusions with treatment success, while 35 patients were classified as short fusions with treatment failure. Regression analysis identified the predictors of treatment success in patients with fusion construct extending beyond T4: baseline sacral slope ≤33.5° (OR: 15.0), not undergoing high grade (PSO or VCR) osteotomy (OR: 15.0) and being Ames descriptor type C (OR: 13.5); all p 6 (OR: 4.3), Ames descriptor type CT (OR: 11.5), Ames cSVA modifier grade 1 or 2 at BL (OR: 4.56), and Flatneck Lafage morphotype (OR: 4.5); all p CONCLUSIONS Treatment success in patients with fusion constructs extending into the thoracic spine vs treatment failure in patients with short fusions may be reliably predicted by the location of the deformity apex, measures of surgical invasiveness, and preoperative deformity severity. Specifically, treatment success in longer fusions is related to deformity apex in the cervical spine and having deformity where adequate correction does not necessitate high grade osteotomy. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Patients receiving surgery for adult spinal deformity (ASD) are often frail and may be at risk of adverse events following these intensive procedures, including proximal junctional failure (PJF). The role of physiologic age in prognosticating this outcome is not well define PURPOSE To determine if the benefits of optimal realignment on PJF development can be negated by increasing frailty as determined by physiologic age. STUDY DESIGN/SETTING Retrospective cohort study of prospective, multicenter ASD database PATIENT SAMPLE A total of 245 ASD patients. OUTCOME MEASURES Complications. METHODS Complications RESULTS A total of 245ASD patients met inclusion criteria (57yrs±15.0, 82%F, BMI: 26.3 kg/m2 ±6.0, ASD-FI: 2.9±1.6, CCI: 1.55 ±1.7). Surgical patients had a mean levels-fused of 11.4±4, LOS of 7.7 days±4.4, EBL of 1686 mL, operative time of 374 min, with 70% undergoing an osteotomy. In terms of surgical approach, 76% were posterior-only and 23.6% had a combined approach. Of the 245 patients, 138 (55%) of patients were characterized as not frail, 107 (43%) as frail. Overall rate for PJK was 49%, and 12% for PJF. The presence of PJF in the NF group was lower than in the F group, (7% vs 18%; p CONCLUSIONS Frailty is a significant independent predictor of PJF development, and while optimizing realignment may minimize this effect, frailty still remains a risk factor. The alarmingly high rates of PJF despite adequate alignment in frail patients warrants further research to determine whether operating on very frail patients with large deformity is advisable. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT The widely used definition for distal junctional kyphosis (DJK) includes the change in kyphosis between the lower instrument vertebra (LIV) and LIV-2 to be >10°. However, this cut-off has yet to be analyzed against other possible cut-offs in terms of accuracy, sensitivity, and specificity for various clinically relevant outcomes. PURPOSE Create thresholds that more accurately predict DJK than those currently used. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Cervical deformity (CD) patients (C2-C7 Cobb >10°, CL>10°, cSVA >4cm, or CBVA >25°) with radiographic data at baseline (BL) and at least 1 year follow-up. OUTCOME MEASURES DJK reoperation, minimal clinical important difference (MCID) for Neck Disability Index (NDI) and EQ5D. METHODS Surgically treated CD patients were enrolled into a prospective, multicenter database and evaluated at a minimum of 1-year follow-up for DJK. DJK was defined by the patient's DJK angle (DJKA) >10° change in kyphosis between LIV and LIV-2 and a >10° index angle. Sensitivity (true positive [TP]/TP+false negative [FN]), precision (true negative [TN]/(TN+False Positive [FP]), and accuracy (TN+TP/TN+TP+FN+FP) metrics were calculated from different combinations of angular changes above and below the lower instrumented vertebrae (LIV) from pre- to postop. The ability of these angular changes to predict different types of DJK failure (DJKF) [(1) reoperation for DJK (2) not meeting MCID for either NDI or Eq5D] and were compared against previously published definitions of DJK including absolute and ∆DJKA>10° and ∆DJKA >20°. RESULTS A total of 160 CD patients with follow-up were included (57yrs, 29.1 kg/m2, 51.8%F). Eighteen percent of these patients developed DJK postop (33.4% 6M, 47.6% 1Y, 19% 2Y). The mean DJK angle prior to revision surgery was -1.7±7.4 (Minimum: -19.3, Maximum: 10.5). Baseline average pelvic parameters were: PT: 16.8±9.6, PI: 54.1±12.3, PI-LL: -2.0±13.5. The average cervical parameters were: TS-CL: 25.6±14.5, C2-C7: -0.9±14.4. Sensitivity, precision, and accuracy of previously used criteria of >10° to identify DJKF for outcome 1 demonstrated a sensitivity of 50%, specificity of 64.4% and an accuracy of 63.2%. For outcome 2 using this criterion resulted in a sensitivity of 55%, specificity 75.8%, and accuracy 67.3%. However, if the ∆DJKA was increased to 15.3, the predicted sensitivity for DJKF defined by reoperation was 50%, specificity 86.6% and with an accuracy of 83.6%. When DKF was defined by HRQLs the sensitivity was 35%, specificity 96.5% and accuracy of 71.4%. This newly established cut-off had greater ability to correctly identify true positives than the 20° cut-off (45.8% vs 27.1%), as well as for true negatives when compared to the 10° (39.2% vs 34.2%). A subanalysis identified 40.6% of patients with a DJKA >10° to be not clinically meaningful. When increasing the angle to the proposed 15.3° only 35.7% are not clinically meaningful. CONCLUSIONS The newly established cut-off for DJK failure (∆DJKA>15.3°) demonstrated greater sensitivity, specificity, and precision than the previously established criteria of 10° when analyzing distal junctional kyphosis failure as described by reoperations or clinical deterioration. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT PROMIS is a computer based adaptive test. However, there is a lack in research in whether these PROMIS scores translate into clinically relevance and applicability in patients at higher operative risk categories. PURPOSE Assess if the PROMIS metric can be utilized to establish a gradient to evaluate complication occurrence alongside ODI. STUDY DESIGN/SETTING Retrospective review of a single-center stereo-radiographic database. PATIENT SAMPLE Patients receiving spinal corrective procedures with complete baseline radiographic and PROMIS data. OUTCOME MEASURES PROMIS metrics (Pain Intensity, Physical Function, Pain Interference). METHODS Surgical patients ≥18 years old with available baseline (BL) radiographic and PROMIS data were isolated in the Quality Database. The relationship between ODI and PROMIS was assessed via linear trends to determine whether the two have discriminative power over each other. The linear trend was mapped between ODI and PROMIS, and patients were divided into quartiles via calculations of perpendicular lines at quartile points to determine whether there was a higher density of complication occurrences at the higher quartile of this association. RESULTS A total of 231 patients (58.7 years, 49.8% female, 29.3kg/m2, mean Charlson comorbidity score: 1.2) met inclusion criteria. By surgical approach: 74.5% posterior, 11.3% anterior, 14.3% combined; mean levels fused: 1.0±0.1. Of the patients included in the study, 155 had both BL ODI and PROMIS data. There were 65 patients in the upper 50th percentile of both ODI and PROMIS. This quadrant of patients experienced a significantly higher complication rate (24.6%) compared to the remainder 10.1% (p=0.016). A linear relationship for ODI vs PROMIS was established (R2=0.4548). There were 36 patients in the 0-25th percentile, 42 in the 25th-50th, 39 in the 50th-75th and 37 in the 75th-100th. Density of complication occurrence was highest at the highest percentile, as 32.4% of patients in the 75th-100th group experienced a complication compared to 2.8% of the 0-25th, 16.7% of the 25th-50th and 12.8% of 50th-75th. CONCLUSIONS Utilizing both ODI and PROMIS scoring systems can guide proper delineation of patients based on their baseline radiographic severity. Based on the results of our study, it appears that these scoring systems used in conjunction may serve as a more appropriate metric to predict postoperative complications, rather than their independent utility. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Robot-assisted surgical techniques are being increasingly implemented to increase surgeon accuracy and stamina; however, further investigation of the introductory phase of robot technology on surgical outcomes remains warranted. PURPOSE To assess complication rates of robotic surgery in elective spine patients. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE A total of 10,501 elective spine patients. OUTCOME MEASURES intra- and postoperative complication rates; reoperation rate. METHODS Patients ≥18 years undergoing elective spine surgery with BL to 2-year follow-up were isolated in a single-center spine database. Patients were grouped by absence or presence of robotic assistance during operation. Univariate analyses identified differences in perioperative outcomes [op time, estimated blood loss, length of stay], rates of intraoperative [durotomy, massive blood loss, neurologic deficit] and postoperative complications [cardiopulmonary, neurologic, GI, GU, infection, mechanical], and reoperation rates by 2Y postop]. Regression analysis assessed the impact of robotic surgery on outcomes. RESULTS A total of 10,501 patients met inclusion criteria (57years, 49% F, 29.0kg/m2) and underwent elective spine surgery (mean levels fused: 3.0±3.3, EBL: 375mL, op time: 206 min, mean UIV: T9, mean LIV: T12). Of these patients, 424 (4.0%) underwent operation with robotic assistance. Compared to a general cohort of elective spine surgery patients, robotic-assisted surgeries had lower levels fused (1.99 vs 3.07), longer op time (301 vs 202min), and longer LOS (4.2 vs 3.2 days); all p 0.05). Robotic and non-robotic patients did not differ in rates of intraoperative complications, including durotomy, massive blood loss, and delayed extubation (all p>0.05). Robotic patients had higher rates of postop ileus (12% vs 7%, p=0.04), but did not differ in overall postop complications, surgical site infection, cardiopulmonary, mechanical, or neurologic complication. Robotic patients had higher rate of reoperation (6% vs 4%, p=0.004). Regression analysis controlling for revision status, decompression, and approach found that robotic surgery patients had lower odds of delayed extubation (OR: 0.155 p=0.025). Robotic surgery did affect the odds for other complications, including durotomy, neurologic, cardiopulmonary, mechanical, infection, and reoperation (all p>0.05). CONCLUSIONS Robotic and non-robotic procedures for elective spine patients were equally as safe in terms of intraoperative and postoperative complications with equivocal functional outcomes up to 2-years postoperatively. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Advances in surgical technique and instrumentation have enabled surgeons to treat symptomatic adult spinal deformity in high-risk populations such as elderly and osteoporotic patients that previously had more limited treatment options. Adjacent segment disease is a significant complication of spinal deformity surgery and is especially relevant in the osteoporotic population. Consequences of osteoporotic vertebral compression fractures in segments adjacent to previous spinal fusion exist on a spectrum ranging from asymptomatic, benign PJK on one end to severe (proximal junctional failure) PJF on the other. As the elderly cohort of the population continues to increase, further research will be required to better understand the causes and treatment of the condition.

BACKGROUND CONTEXT Distal junctional kyphosis (DJK) remains a primary concern for surgeons performing cervical deformity (CD) surgery. Postoperative complications from CD surgeries often render patients with worse recovery profiles which require reoperation. It is paramount to understand possible DJK recovery profiles for various types of surgical patients. PURPOSE Identify if DJK patients successfully recover from treatment/reoperation. STUDY DESIGN/SETTING Retrospective review of prospectively collected database. PATIENT SAMPLE This study included 145 cervical deformity (CD) patients with baseline and 1-year follow-up. OUTCOME MEASURES Complications;reoperations; HRQL, alignment. Methods CD patients(patients) were identified if they developed DJK. DJK angle (DJKA) was defined as >10° change in kyphosis between LIV and LIV-2 and a >10° index angle. Patients were stratified into two groups: 1) those who received a reoperation for DJK (Reop DJK) and those that did not have DJK (no DJK). Normalized HRQL scores at baseline and follow-up intervals (3 months, 6 months, 1 year, 2 years) were generated. Normalized HRQLs were plotted and area under the curve was calculated, generating one number describing overall recovery (Integrated Health State [IHS]). Results A total of 145 CD patients included. Of these patients, 32% developed DJK postop (56 years, 28.5kg/m2, 53% Female) with 12.8% of these cases being severe. By DJK occurrence: 24.2% within 3 months, 45.4% at 6 months, 31.4% by 1 year. Of these DJK patients, 25.5% received a reoperation. Upon presentation, Reop DJK patients had a worse PI-LL (-11.0 vs .11), worse NSR-Neck (8.7 vs 6.9), and a worse NDI (65.7 vs 53.9; all p 0.05). Having DJK and not receiving a reop did not have much of an effect on recovery despite DJK angle, however; when compared to DJK reop, when nonop DJK angle was greater than 20°, the IHS-score mJOA adjusted resulted in greater long-term recovery (nonReop:59.9 vs Reop: 48.4; p Conclusions Of the total DJK patients in this study, 25.5% received a reoperation. These patients had a worse pain recovery profile than non-DJK patients. However; when matched to their age-adjusted SVA, reop DJK patients were shown to have an improved short-term recovery than if they went unmatched according to their IHS-adjusted NSR-Neck. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Distal junctional kyphosis (DJK) development after cervical deformity (CD) corrective surgery is a growing concern for surgeons and patients. Although proper realignment is known to help mitigate the development of DJK, there has yet to be a study that critically analyzes under correction in certain parameters and the effects on development of DJK. PURPOSE To determine the effects of under correction in the development of DJK. STUDY DESIGN/SETTING Retrospective cohort study of single-center database. PATIENT SAMPLE This study included 195 CD patients. OUTCOME MEASURES Complications; radiographic parameters; HRQL metrics (NDI, EQ5D, mJOA, NRS Neck). METHODS Inclusion criteria: operative CD patients (cervical kyphosis >10°, with cSVA>4cm or CBVA>25°) and >18yrs with up to 2-year radiographic and HRQL follow-up. Significant differences in surgical, radiographic, and clinical factors and outcomes were determined. Under correction was defined by a deformity in TS-CL or cSVA Ames Modifier. Moderate Ames cervical lordosis deformity (CL) was TS-CL >15 and high >20, high cSVA deformity was >8cm. RESULTS A total of 195 CD patients met inclusion criteria (58.3yrs, 46% Female, 28.3 kg/m2). Overall, 40 (21%) of these patients developed DJK. At baseline patients presented with the following radiographic profile: PT (18.3), PI-LL (-.65), SVA C7-S1 (-6.54), cSVA C2-C7 (9.7), and TS-CL (24). Patients undercorrected in TS-CL developed DJK at a greater rate (28% vs 15%, p=.02), and patients undercorrected in cSVA developed more DJK (65% vs 16%) and underwent more reoperations (42% vs 17%, both p 0.05). CONCLUSIONS The TS-CL and cSVA components of Ames criteria show a strong correlation with development of distal junctional kyphosis (DJK). Thresholds for DJK development suggests even patients who fall into a mild deformity as per the Ames criteria are still at an increased risk, and more strict alignment goals may further prevent mechanical failure. cSVA was found to be the dominant radiographic parameter impacting DJK development. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Global spinal malalignment plays a vital role in cervical spinal deformity corrective surgery outcomes; however, the literature is scarce on the effects that the individual sagittal parameters have on outcomes. PURPOSE To investigate the impact of sagittal malalignment on cervical deformity patient outcomes. STUDY DESIGN/SETTING Retrospective cohort study of single-center database. PATIENT SAMPLE This study included 123 CD patients. OUTCOME MEASURES Complications; radiographic parameters; HRQL metrics (NDI, EQ5D, mJOA, NRS Neck) METHODS Inclusion criteria: operative CD patients (cervical kyphosis >10°, with cSVA >4cm or CBVA >25°) and >18yrs with up to 2Y radiographic and HRQL follow-up. Significant differences in surgical, radiographic, and clinical factors and outcomes were determined. Deformity in PT, SVA, and PILL was defined using the SRS-Schwab criteria. “Unmatched” refers to patients who were under corrected or over corrected according to the Schwab age-adjusted parameters (Lafage et al.). RESULTS A total of 123 CD patients met inclusion criteria (58.3 yrs, 46% Female, 28.3 kg/m2). Overall, 27 (24%) of these patients developed DJK. At baseline, patients presented with the following radiographic profile: PT (18.3), PILL (-.65), SVA C7-S1 (-6.54), cSVA C2-C7 (23.5), and TS-CL (25.2). Patients with DJK had a higher L1-S1 (34 vs 9.2) and T12-S1 (57 vs 35, both p 0.05). Patients with a deformity in PT at baseline developed more DJK by 2 years (26% vs 11%), had more DJF (7% vs 2%) and a higher NDI and NSR back pain. Patients with mismatch at baseline had higher rates of DJK (30% vs 22%), and patients with SVA deformity at baseline had a lower mJOA, SWAL Food selection, SWAL Communication, and a higher EQ5D. Patients with a mismatched alignment in Roussouly preoperatively had higher rates of DJK at 3M (18% vs 12%), 6M (26% vs 16%), 1Y (24% vs 14%), and 2Y (26% vs 13%, all p CONCLUSIONS Global spinal malalignments play an important role in the outcomes of cervical spinal deformity corrective surgery. The presence of abnormal global sagittal malignment at baseline is associated with higher rates of DJK development and worse clinical outcomes, while patients who maintained poor sagittal alignment up to 2Y were associated with significantly greater development of DJK and inferior neck disability index scores. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT As surgery is increasingly recommended for patients with spinal instability and neurologic deterioration secondary to central cord syndrome (CCS), it is important to investigate the impact age has on postoperative complication rates. PURPOSE Investigate associations of age and surgical decision and timing of procedure. STUDY DESIGN/SETTING Retrospective review of Health care Cost and Utilization Project's Nationwide Inpatient Sample (NIS). PATIENT SAMPLE CCS patients. OUTCOME MEASURES Surgical timing and postop complications. METHODS CCS patients (ICD-9 codes 952.03, 952.08, 952.13, 952.18) were isolated in the NIS database 2007-2016. As appropriate, analysis of variance and chi-squared tests compared demographics, and Charlson Comorbidity Index (CCI) scores. Patients were then stratified by age into 4 percentiles (1st: 13-48, 2nd: 49-50, 3rd: 59-68, 4th: 69-90). Surgical decision-making such as approach and surgical timing were analyzed for their association with postoperative complications via logistic regressions controlling for CCI. An age cutoff in relation to postop complications was identified via Receiver Operating Curve (ROC). RESULTS There were 5,725 CCS patients included (59.5years, 1.3 CCI, 26% Female). By age percentile, those that were in the lowest had greater rates of decompressions (71.8%), fusions (88.4%), combined approach (5.1%), anterior approach (64.4%), and 9+ levels fused (3.5%; all p 59 years had an increased likelihood of postoperative complication development (AUC: 0.5, p=0.002). CONCLUSIONS Age overall played a role in postoperative complications when >59 years. It also played a significant role in surgical timing and surgical approach. Adequately stratifying patients diagnosed with Central Cord Syndrome in accordance to their age profile can minimize postoperative complications. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Increasing pelvic tilt (PT) is a primary compensatory mechanism in adult spinal deformity (ASD). By SRS-Schwab criteria, PT >20° is considered pathologic. Some ASD patients improve their PT following ASD correction, while others do not. The driving forces behind this lack of PT-response are not well defined. PURPOSE To determine the perioperative characteristics associated with PT normalization after ASD corrective surgery. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE A total of 176 ASD patients. OUTCOME MEASURES Patient profile, radiographic parameters, and surgical factors associated with PT normalization. METHODS Operative ASD patients fused to S1/pelvis with full preoperative data as well as preoperative (BL), 6-week (6W), 1-year (1Y), and 2-year (2Y) postop PT measurements were included. PT normalization was assessed at 6W and 2-year follow-up. Univariate analyses were used to compare normalized (PTNorm) and non-normalized (NON) patients in terms of demographics, surgical and radiographic descriptors, postoperative alignment, and clinical outcomes. Multivariate regression and ROC curve assessed periop factors predicting 6W PT normalization. Conditional inference tree (CIT) determined thresholds for the continuous variables identified as independent predictors of PT normalization. RESULTS There were 176 ASD patients that met inclusion criteria (62.9±10.2years, 80%F, BMI 26.9±4.9 kg/m2, CCI: 1.88), and underwent surgery (levels fused 12.1±3.9, EBL: 1955mL, op time: 402min). At each time point, mean PT was as follows: BL: 25.7o, 6-week: 19.0o, 1-year: 21.2o, and 2-year: 22.3°. Patients classified as having normal PT by SRS-Schwab criteria (PT 0.05). Six weeks PTNorm patients were more likely to be overcorrected in PT, PI-LL, and SVA compared to NON patients at 6 weeks postop (all p 10, invasiveness score >109, baseline cSVA CONCLUSIONS PT normalization following ASD correction occurred in almost 40% of patients by 6 weeks postop. Normalization is more likely to occur in patients where reconstruction addresses lumbopelvic mismatch, extends above the apex of the thoracic kyphosis, and has adequate surgical invasiveness to achieve full alignment correction. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT For patients undergoing a cervical spine procedure, the effect of a shoulder injury on perioperative outcomes is not well understood. Our study aimed to investigate the impact shoulder injuries have on perioperative outcomes for elective cervical spine surgery patients. PURPOSE To evaluate the effect of concomitant shoulder injuries on perioperative outcomes of elective cervical spine surgery. STUDY DESIGN/SETTING Retrospective review of a national patient database between 2007-2017. PATIENT SAMPLE A total of 1,482,311 elective cervical spine surgery patients. OUTCOME MEASURES Comorbidity burden, invasiveness, perioperative complications, length of stay (LOS), total hospital charges. METHODS Patients undergoing elective cervical spine surgery were isolated with ICD-9 diagnosis codes. Cervical procedure (CP) patients with concurrent shoulder diagnosis(S-Dx) were further isolated. Means comparison tests compared differences in demographics, surgical, and perioperative outcomes between those who had a cervical procedure and a concurrent shoulder diagnosis (CP/S-Dx) and those who had a cervical procedure with no shoulder diagnosis (CP). Logistic regression analysis assessed the odds of complication associated with a shoulder diagnosis, controlling for age and surgical invasiveness. RESULTS 1,482,311 elective cervical spine surgery patients were included. Overall, 17,873(1.2%) patients underwent a CP and had a concurrent S-Dx. CP and S-Dx patients compared to only CP patients were significantly younger and male (both p CONCLUSIONS Patients with a concurrent shoulder diagnosis undergoing a cervical spine procedure were 30% more likely to experience a perioperative complication compared to those without a shoulder injury. Prior to proceeding with surgery, providers should consider the effect of shoulder injuries on outcomes of cervical spine procedures. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Adult spinal deformity is associated with severe pain and disability. Recent literature has shown that surgical intervention can significantly improve patients’ quality of life and lessen disease burden. As many patients requiring spine surgery are elderly and often frail, restoration of alignment targets may differ. The literature is scarce on how different frailty states affect realignment goals. PURPOSE Modify the age-adjusted alignment goals using the Frailty Index to optimize outcomes in surgical adult spinal deformity (ASD) patients. STUDY DESIGN/SETTING Retrospective cohort study of a prospective multicenter database of ASD patients. PATIENT SAMPLE This study included 245 ASD patients. OUTCOME MEASURES Complications, HRQLs (SRS-22, ODI, SF-36). METHODS Operative ASD patients (scoliosis ≥20°, SVA ≥5cm, PT ≥25°, or TK ≥60°) with available baseline and 2-year radiographic and HRQL data were included. ASD frailty index was used to stratify patients into not frail (NF) and frail (F) categories. Linear regression analysis established normative radiographic thresholds, utilizing previously published age specific US-Normative ODI values (Lafage et al) and the frailty index, based on a cohort of patients with an ideal clinical outcome (no major complications, no PJK, and an SRS-satisfaction of >4). Patients were considered “matched” if 2-year postop alignment was within 1 standard deviation (+1SD overcorrected-1SD undercorrected). RESULTS A total of 245 patients included (57±15yrs, 82% female, 26±5.14kg/m2, ASD-FI: 2.9±1.6, CCI: 1.8 ±1.7). Patients had a mean level fused of 11.1±4.4, LOS of 7.7 days±4.4, EBL of 1577 mL, operative time of 377 min, with 63% undergoing an osteotomy. In terms of surgical approach, 69.9% posterior-only, and 29.3% had a combined approach. Primary analyses demonstrated correlation between baseline frailty index, PT, PI-LL, SVA, and ODI, (p CONCLUSIONS Age-adjusted alignment by Lafage et al was the first study to recognize that older age warrants a lower degree of correction, and, the original SRS-Schwab criteria was modified accordingly. Alignment targets accounting for both frailty and age were developed with larger thresholds for increasing frailty. In this study, we found patients who were matched in these age and frailty adjusted thresholds had lower rates of PJF and significantly improved HRQL outcomes. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT With health care costs on the rise, hospitals have increasingly focused on providing economically efficient medical services. Adult spinal deformity surgery remains an expensive medical intervention with high risk for complications and revisions, especially following mechanical failure in the context of proximal junctional kyphosis (PJK). We sought to evaluate the impact of PJK on associated expenditures following an index surgery for ASD. PURPOSE To evaluate the effect of proximal junctional kyphosis on the cost effectiveness of corrective adult deformity surgery. STUDY DESIGN/SETTING Retrospective cohort study of a prospective single-center database of ASD patients. PATIENT SAMPLE A total of 147 Adult Spinal Deformity Patients. OUTCOME MEASURES Complications, HRQLs (Oswentry Disability Index [ODI]), Quality adjusted life years (QALY). METHODS Adult Spinal deformity patients with 2-year HRQL follow-up were included. Utility data was calculated using published conversion methods to convert ODI to SF-6D. QALYs utilized a 3% discount rate to account for residual decline to life expectancy (78.7 years). Costs were calculated using the PearlDiver database incorporating complications and comorbidities classified according to CMS standard definitions. Reimbursement consisted of a standardized estimate using regression analysis of Medicare pay-scales for all services rendered within a 30-day window, including estimates regarding costs of postoperative complications, outpatient health care encounters, reoperations and revisions. After accounting for all postoperative events, including mortality, cost per QALY by 2Y was calculated for revisions that occurred due to proximal junctional kyphosis. RESULTS A total of 147 adult spinal deformity patients met inclusion criteria (55.22years, 54% Female). At baseline, patients presented radiographically as: Pelvic Tilt (23.66±11.7), Pelvic Incidence- Lumbar Lordosis (-2.9±12.6), Sagittal Vertical Axis (60.5±76.8), T1 Pelvic Angle (22.6±14.3). Surgical details: EBL of 1823 mL, operative time of 327 min, with .4% undergoing an anterior approach, 90.2% posterior-only approach, and 9.3% combined approach. Overall, 54.3% of patients developed PJK within 2 years postoperatively, with 22% undergoing reoperation for PJK. Average cost of revision surgery due to PJK was $93,688 ± $21,467. The cost for PJK patients, including the cost associated with their revision surgery, was higher ($103,760 vs $71,000). Baseline ODI (39 vs 32) and 2Y ODI (39 vs 27) were higher for PJK patients, however, PJK patients did improve to a greater degree (-12 vs -10). The overall cost per QALY by 2Y was higher for PJK patients ($116,170 vs $95,347). CONCLUSIONS Patients that developed PJK had an almost $30,000 higher initial cost at 2 years. When looking at the cost per quality adjusted life years by 2Y, PJK resulted in slightly more than $20,000 in cost. These findings suggest prophylactic measures to mitigate PJK may improve the cost utility of adult spinal deformity surgery and can help policy efforts for adequate resource allocation for these complex patients. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Frailty is a dynamic measure of physiological age that is a strong predictor of a patient's surgical risk. The purpose of this study is to investigate the impact of frailty on the perioperative outcomes and costs associated with operating on frail ASD patients. PURPOSE To investigate impact of frailty on operative course, clinical outcomes, and cost utility. STUDY DESIGN/SETTING Retrospective cohort study of prospective, multicenter ASD database. PATIENT SAMPLE A total of 245 ASD patients were included. OUTCOME MEASURES Complications; health-related quality of life (HRQL): ODI. METHODS Operative ASD patients (scoliosis >20, SVA>5cm, PT>25, or TK>60) with available baseline (BL) and 2-year (2Y) radiographic and HRQL data were included. The ISSG frailty index was used to stratify patients into 2 categories: not frail (NF) ( 3). Univariate and multivariate analysis assessed differences in radiographic, surgical, and clinical factors. IHS-adjusted ODI and SRS compared recovery periods between F/NF patients. Cost utility using published methods convert ODI to SF-6D obtained Quality Adjusted Life Years (QALY). QALYs utilized a 3% discount rate for residual decline to life expectancy (78.7 years). Direct costs calculated using the PearlDiver database incorporating complications, LOS and associated health care costs. RESULTS A total of 245 ASD patients met inclusion criteria (57yrs±15.0, 82%F, BMI: 26.3 kg/m2 ±6.0, ASD-FI: 2.9±1.6, CCI: 1.55 ±1.7). Surgical patients had a mean number of levels fused of 11.4±4, LOS of 7.7 days±4.4, EBL of 1686 mL, operative time of 374 min, with 70% undergoing an osteotomy. In terms of surgical approach, 76% were posterior-only, and 23.6% had a combined approach. Frailty breakdown was: 138 (55%) NF and 107 (45%) F patients. F patients had higher mean PT (25 vs 20), PILL (21 vs 10), TK T4-T12 (-33 vs -36), SVA C7-S1 (80 vs 35), and a higher BL ODI (52 vs 27, all p CONCLUSIONS Frail patients experienced a longer LOS and higher EBL, possibly due to the increased invasiveness used to treat a more severe deformity with a worse preoperative physiological state. Although frail patients experienced more complications, the higher overall improvement in ODI contributed to a comparable cost utility despite a higher initial cost. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Surgical correction of cervical deformity (CD) has been associated with superior alignment and functional outcomes. It has not yet been determined whether baseline and postoperative T1 slope and C2 slope correlate with health-related quality of life (HRQL) metrics and radiographic complication. PURPOSE To determine the impact of T1S and C2S deformity severity on HRQL metrics and DJK development in operative cervical deformity patients. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE A total of 119 CD patients. OUTCOME MEASURES Radiographic parameters; HRQLs. METHODS Included: Operative CD patients with UIV above C7 and with pre-(BL) and up to 2-year (2Y) postop radiographic/HRQL data. Cervical deformity was defined as meeting at least one of the following radiographic parameters: C2-C7 lordosis 35°, segmental cervical kyphosis >15° across any 3 vertebra between C2-T1, C2-C7 SVA >4cm, McGregor's slope >20°, or CBVA > 25°. Spearman's rank-order correlation and linear regression analysis assessed the impact of baseline T1 slope (T1S) and C2 slope (C2S) on baseline HRQL metrics (NDI, mJOA, EQ5D, NRS Neck, NRS Back), and the impact of postoperative T1S and C2S on follow-up HRQLs. Logistic regression and conditional inference tree (CIT) machine learning were used to determine baseline radiographic thresholds for improving in ≥2 HRQL metrics from BL to 2Y, and 2Y radiographic thresholds for developing DJK or DJF by 2Y postop. RESULTS A total of 119 CD patients met inclusion criteria (61.2±10.5years, 63%F, BMI 29.0±7.5kg/m2, CCI: 1.00±1.31) and underwent surgery (levels fused 7.5±3.7, EBL 990mL, op time 547min). By approach, 19.3% anterior-only, 44.5% posterior-only, and 36.1% combined. Mean BL radiographic parameters: PT 19.6°, PI-LL 1.4°, SVA 1.9mm, T2-T12 kyphosis -46.8°, C2-C7 lordosis -9.0°, T1S 29.0°, TS-CL 38.2°, C2S 37.7°, cSVA 44.0mm, and C2-T3 -18.0°. Mean BL HRQLs were as follows: NRS back 5.0, NRS neck 6.7, NDI 47.9, mJOA 13.5, and EQ5D 0.74. Spearman correlation and linear regression identified no association between baseline T1S or C2S and HRQL metrics, or between 2Y postop T1S and HRQLs (all p>0.05). Correlation and linear regression found significant associations of higher C2S with higher NDI (p=0.042), lower mJOA (p=0.011), and lower EQ5D (p=0.009), all indicating higher degree of disability at 2Y postop. Logistic regression with CIT identified thresholds for improving in 2 or more HRQL metrics by 2Y postop: baseline T1S 45.3° (OR: 16.0) and C2S >32.5° (OR: 6.07); both p CONCLUSIONS Baseline deformity severity in terms of T1 slope and C2 slope can be predictive of postoperative functional outcomes in cervical deformity patients, while postoperative deformity in T1S and C2S can be predictive of DJK and DJF occurrence. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Chiari malformations (CM) are congenital or acquired hind brain anomalies with resultant cerebellar tonsillar herniation through the foramen magnum. These malformations are classified by the severity of the disorder as Types I-IV, each type presenting with associated features and anomalies. Despite significant research on Chiari malformations, clinical features and management options have not yet conclusively evolved. PURPOSE This study aims to identify different surgical variables and complication rates for CM sub-types. STUDY DESIGN/SETTING Retrospective cohort study of HCUP's KID (Kids’ Inpatient Database), PATIENT SAMPLE A total of 35,073 Chiari Malformation patients in KID during the years of 2003-2012. OUTCOME MEASURES Perioperative outcomes in surgical spine patients (patients). METHODS The KID database was queried for diagnoses of operative Chiari Malformation from 2003-2012 by ICD-9 codes. Differences in preoperative demographics (age/BMI) and perioperative complication rates between patient cohorts were assessed using Pearson's chi-squared tests and T-tests when necessary. Binary logistic regression, which controlled for age and LOS was used to assess the contribution Chiari's has on complication rate. Level of significance was set to p RESULTS There were 34,982 Chiari patients isolated from KID (3.17years ±6.4, 49.5F%). Of these, 39.4% were type I, 6.1% were type III, and 55.4% were type IV. Also, 5.6% of these Chiari patients experienced complications (CM-I=8.2%, CM-III=5.5%, CM-IV=3.7%; p=0.00). CM -I and IV primary diagnoses increased over time (Type I: 31.1% to 38.4%, Type IV: 17.3% to 20.8%; all p CONCLUSIONS CM-1 patients were identified to have greater complication rates irrespective of procedure, most of which were less serious than other subtypes, type while CM-III and CM-IV were identified to be affected by receiving a more extensive decompressions and have more serious adverse complications. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Incorporation of open and MIS robotic techniques in spine surgery has been growing over the past decade, resulting in altered surgical techniques and the need for newly developed skills. With the initial learning curve involved in using this new technology, the upfront risk of complications and poor outcomes during the learning process has been understudied in the literature. PURPOSE To evaluate the initial risk of complications with the incorporation of robotic assisted spine surgery. STUDY DESIGN/SETTING Retrospective review of a national patient database between 2007-2016. PATIENT SAMPLE A total of 3,759,824 elective spine surgery patients. OUTCOME MEASURES Comorbidity burden, perioperative complication rates, year-to-year complications, mechanical complications. METHODS Inclusion criteria: elective spine surgery procedures from 2007-2016 as defined by ICD-9-CM and ICD-10-CM codes. Exclusion criteria: emergency, trauma or nonelective surgery. Descriptive statistics assessed demographic information. Rates of open and MIS robot-assisted procedures were assessed, as well as trends in postoperative complications and length of stay. Logistic regressions were performed to see if robotic use was independently predictive of a postoperative complication. RESULTS The study included 3,759,824 elective spine surgery patients. Overall, 4,185 patients underwent robotic spine surgery (0.1%). There was a significant increase from in robotic surgery cases from 2010 to 2016 with 11 patients in 2010 to 1,535 patients in 2016 (p CONCLUSIONS The rise of robotic assisted spine surgery has yielded a concurrent rise in perioperative complications as surgeons adjust to this new technology. Until the learning curve lessens for incorporation of robotic techniques in spine surgery, providers should weigh MIS or open robotic procedures with an eye towards perioperative complications. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Recent studies have suggested that in patients with neck pain, both psychological and physical symptoms need to be addressed. Cognitive behavioral therapy (CBT) works to address risk factors through education about pain, modification of maladaptive beliefs, and increasing patient's self-efficacy. PURPOSE To determine the long-term effectiveness of brief psychological intervention on psychological outcomes in cervical spine surgery. STUDY DESIGN/SETTING Prospective, blinded, and placebo-controlled trial. PATIENT SAMPLE Forty-eight patients undergoing cervical spine surgery. OUTCOME MEASURES Fear Avoidance Beliefs Questionnaire (FABQ), Pain Catastrophizing Scale (PCS), Neck Disability Index (NDI), modified Japanese Orthopedic Association (mJOA), visual analog scale (VAS), EuroQol Five Dimensions (EQ5D), Numeric Rating Scale (NRS) for neck and arm pain. METHODS To date, 48 patients age >18yrs with symptomatic cervical degenerative disease have been enrolled in the RCT. All patients underwent elective cervical surgery of ≤5 levels, and had an NDI >20%. Patients who met psychological distress criteria [DRAM >17 and 49 and 30 and RESULTS A total of 48 patients enrolled (53.6yrs±10.7yrs, 49% female, 29.6±5.9kg/m2), and underwent surgical correction (levels fused 2.2±1.5, EBL: 111mL, operative time: 177min). By surgical approach, 80% underwent anterior-only, 16% posterior-only, and 4% combined. By randomization group: 17 (35.4%) CBT, 12 (25.0%) Sham, 10 (20.8%) Control, and 9 (18.8%) DRAM. All patients had HRQL data collected preoperatively; 33 patients (68.8%) completed 2Y follow-up. Overall, the following number of patients improved from BL to 2Y in each HRQL: PCS – 21, FABQ – 16, mJOA – 18, NDI – 24, EQ5D – 17, VAS – 21, NRS Neck – 20, NRS Arm – 21 patients. Univariate analysis showed that patients in the CBT group trended toward a higher rate of improvement in PCS (56% vs other groups: 41%, p=0.338), FABQ (50% vs 28%, p=0.133), NDI (69% vs 45%, p=0.124), EQ5D (50% vs 31%, p=0.209), VAS (63% vs 38%, p=0.114), NRS Neck (56% vs 38%, p=0.236), and NRS Back (63% vs 38%, p=0.114). These trends were maintained when comparing the CBT group with each of the Control, Sham, or DRAM Observational groups individually. CONCLUSIONS While limited by sample size, clear trends in our cohort of operative cervical spine patients show that improved psychological and functional outcomes may be achieved with preoperative CBT intervention. Further investigation is warranted to validate these findings. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Improvement capability increases with frailty and deformity severity to a certain point. The present study aimed to identify the range in which a patient would benefit from intervention and what the upper limit for reduced improvement would be due to severe frailty or deformity. PURPOSE Investigate whether there is a range of frailty and radiographic measures at which patients improve in their reported outcomes the most after adult spinal deformity corrective surgery. STUDY DESIGN/SETTING Retrospective. PATIENT SAMPLE A total of 250 adult spinal deformity (ASD) patients. OUTCOME MEASURES Major complications, Oswestry Disability Index (ODI). METHODS Surgically eligible ASD patients with baseline (BL) and up to 2-year (2Y) ODI were included. Difference between BL and 1Y ODI was calculated, graphed alongside Frailty Index and radiographic measures (sacral slope, pelvic incidence, PI-LL, thoracic kyphosis), and fitted to a polynomial, the vertex representing the value at which patients most improved. Optimal ranges (OR) for these criteria were determined to be within a range of the vertex value. ANCOVA established estimated marginal means while adjusting for covariates including age, sex, and surgical invasiveness. RESULTS Overall, 250 patients (57.0 years, 81.6% female, 26.3kg/m2) were included. BL Frailty value for vertex of polynomial between BL to 1Y ODI improvement and BL Frailty (R2=0.1199): 5.0. Frailty OR patients (between 4.0 and 5.2) had the highest improvement in ODI at 1Y (-20.44) compared to under the OR (-10.33) and over (-17.37, p=0.001). ODI improvement at 2Y: OR=-20.84; under=-12.32; over=-19.31, (p=0.006). Frailty OR had more improved SRS-22 Total Scores at 1Y (1.12; 0.73; 0.98; p=0.001) and 2Y (1.09; 0.77; 1.02; p=0.013). Radiographic vertices: SS=12.14; PI=53.2; PI-LL=53.1; TK=1.36. Patients who were within ±5 (OR) had greater improvement in 1Y ODI (-15.68) compared to no ORs (-11.27; p=0.125). Patients who met ORs for both frailty and at least one radiographic measure had greatest improvement in ODI by 1Y (p=0.017) and 2Y (p=0.068) and lowest rates of major complications (p=0.086) compared to patients who were under or over the frailty OR and/or did not meet at least one radiographic OR. CONCLUSIONS Patients above the determined thresholds have reduced improvement in patient-reported outcomes despite having more “room to improve,” indicating that although capacity to improve is present, frailty or deformity inhibits the ability to do so. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Summary The present study adapts the typical eyewitness misinformation paradigm into an academic context. Unbalanced English–Spanish bilinguals (N = 81) listened to a lecture in English (L1) or Spanish (L2), read notes in L1 or L2, and completed a forced-choice recognition test in the lecture language. Unlike prior studies with proficient bilinguals, unbalanced English-dominant participants showed greater recognition memory accuracy for material presented in English only than did material presented in Spanish only. English misinformation had a greater impact on memory for the Spanish lecture than vice versa. Most importantly, the modified misinformation paradigm is an effective tool to investigate academic misinformation effects and could be used in bilingual and monolingual research. Copyright © 2017 John Wiley & Sons, Ltd.

BACKGROUND CONTEXT NSQIP Surgical Risk Calculator is a web-based decision aid and informed consent tool widely used by surgeons and their patients. This application creates patient-specific risks for those planning to undergo a procedure. Despite its wide use, minimal studies have validated the external applicability of the NSQIP calculator, in the setting of adult spinal deformity. PURPOSE Identify NSQIP risk calculator usability in a population of adult spinal deformity (ASD) patients from a single institution database (Quality). STUDY DESIGN/SETTING Retrospective cohort study of patients with adult spinal deformity between 2011-2018. PATIENT SAMPLE Adult spinal deformity patients. OUTCOME MEASURES Any Complication rate, cardiac complication, SSI, UTI, return to OR and length of stay (LOS). METHODS ASD patients were isolated in Quality (2011-2018). CPT codes for ASD patients were utilized in the NSQIP calculator in order to create baseline expectations for patient outcomes. 7 variables shared among Quality and NSQIP risk calculator were identified for average predictive values. The same perioperative outcomes collected from the NSQIP calculator was then analyzed in the Quality database. Pts were further stratified by frailty (not frail [NF] 0.5). Brier scores were calculated for each variable in order to validate the calculator's predictability in Quality. Having a score closer to 1 means the NSQIP calculator is not predictive of that specific outcome. A score closer to 0 means the NSQIP calculator was a predictive tool for that factor. RESULTS A total of 1,606 ASD patients were isolated from the Quality (48.7yrs, 63.8%F, 25.8 kg/m2). 33.4% received decompressions and 100% received a fusion. Of these Quality patients, 15.1% had past medical history of hypertension, 3.1% malignant cancer, 5.2% diabetes, 2.6% connective tissue disease and 2.8% chronic pulmonary disease. The average ASD outcome predicted by the NSQIP risk calculator predicted lower rates for NSQIP patients for return to OR (0.8% vs 2.4%), LOS (2.5d vs 6.5d), total complication rate (11.5% vs 16.5%), and cardiac (0.34% vs 1.9%) than Quality patients. The single institution did have lower UTI and SSI outcomes (1.7% vs 2.85%; 1% vs 1.8% respectively). The calculated Brier scores identified the calculator's predictability for each factor: complication total (0.78), cardiac (0.99), SSI (0.99), UTI (0.96), and return to OR (0.92). The only variable predictive among ASD patients was death with a Brier score of 0 in both groups. This was also the only factor among NF patients (Brier score:0). The NSQIP calculator predicted outcomes for F patients that were lower than those identified in the single institution and therefore, didn't have much usability in this population. CONCLUSIONS The NSQIP calculator is not a valid calculator in our single institutional database. It is unable to comment on surgical complications such as return to OR, SSI, UTI and cardiac that are typically associated with poor patient outcomes. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Extensive or persistent calcium phosphate deposition within soft tissues after severe traumatic injury or major orthopedic surgery can result in pain and loss of joint function. The pathophysiology of soft tissue calcification, including dystrophic calcification and heterotopic ossification (HO), is poorly understood; consequently, current treatments are suboptimal. Here, we show that plasmin protease activity prevents dystrophic calcification within injured skeletal muscle independent of its canonical fibrinolytic function. After muscle injury, dystrophic calcifications either can be resorbed during the process of tissue healing, persist, or become organized into mature bone (HO). Without sufficient plasmin activity, dystrophic calcifications persist after muscle injury and are sufficient to induce HO. Downregulating the primary inhibitor of plasmin (α2-antiplasmin) or treating with pyrophosphate analogues prevents dystrophic calcification and subsequent HO in vivo. Because plasmin also supports bone homeostasis and fracture repair, increasing plasmin activity represents the first pharmacologic strategy to prevent soft tissue calcification without adversely affecting systemic bone physiology or concurrent muscle and bone regeneration. © 2016 American Society for Bone and Mineral Research.

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

Selective serotonin reuptake inhibitors (SSRIs) are one of the most commonly prescribed antidepressants worldwide and recent data show significant impairment of fracture healing after treatment with the SSRI fluoxetine in mice. Here, we provide evidence that the negative effects of SSRIs can be overcome by administration of the beta-blocker propranolol at the time of fracture. First, in vitro experiments established that propranolol does not affect osteogenic differentiation. We then used a murine model of intramembranous ossification to study the potential rescue effect of propranolol on SSRI-induced impaired fracture healing. Micro-CT analysis revealed that fluoxetine treatment resulted in a smaller bony regenerate and that this decrease in bone formation can be overcome by co-treatment with propranolol. We then tested this in a clinically relevant model of endochondral ossification. Fluoxetine-treated mice with a femur fracture were treated with propranolol initiated at the time of fracture, and a battery of analyses demonstrated a reversal of the detrimental effect of fluoxetine on fracture healing in response to propranolol treatment. These experiments show for the first time to our knowledge that the negative effects of SSRIs on fracture healing can be overcome by co-treatment with a beta-blocker. © 2019 American Society for Bone and Mineral Research.

BACKGROUND CONTEXT Recent studies suggest that for patients with neck pain, both psychological and physical symptoms need to be addressed. Psychological distress risk factors are associated with poor outcomes in the fear avoidance model, where individuals passively cope through avoidance behaviors and disuse. Cognitive behavioral therapy (CBT) works to address risk factors through education about pain, modification of maladaptive beliefs, and increasing patient's self-efficacy. PURPOSE Determine the effectiveness of brief psychological intervention on outcomes in cervical spine surgery. STUDY DESIGN/SETTING Prospective, blind, and placebo-controlled trial. PATIENT SAMPLE A total of 35 symptomatic Cervical Degenerative Disorders patients. OUTCOME MEASURES Distress and Risk Assessment Method (DRAM), Fear Avoidance Beliefs Questionnaire (FABQ), Pain Catastrophizing Scale (PCS), Outcome Expectation Question (OEQ). Neck Disability Index (NDI), modified Japanese Orthopedic Association (mJOA), Visual Analog Scale (VAS), EuroQol Five Dimensions (EQ5D). METHODS Thirty-five patients age >18 with symptomatic cervical degenerative disease have been enrolled in the study. If patients met psychological distress criteria, they were in the treatment group: DRAM >17 and 49/66, PCS >30/52 or OEQ ≤2 (randomized to CBT or placebo). CBT and sham treatment groups had 6 sessions prior to surgery. The control group had no intervention prior to surgery. Baseline and 3M changes were assessed for all outcome measures. RESULTS A total of 35 patients were enrolled (age 53.9 years, BMI 28.7 kg/m2). Twenty-two patients met psychological distress criteria and were randomized into a treatment group (13 CBT vs. 9 placebo). Thirteen patients were in the control group, with 5 having too high of DRAM scores to be CBT candidates. At enrollment, the average DRAM score was 34.55 ± 13.87, with the DRAM observational group, Placebo, and CBT groups all having higher scores than control patients (45.6 vs 13.4, P CONCLUSIONS Preliminary results of this randomized controlled study on cervical degenerative surgery patients showed that patients who received cognitive behavioral treatment before surgery had better improvement in all psychological related questionnaires compared to non treatment patients. Long-term follow up will assess the changes in psychological and pain related outcomes in these groups to assess the impact of psychological intervention for at risk patients. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT 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. PURPOSE Investigate the rates of PD in elective orthopedic procedures. STUDY DESIGN/SETTING Retrospective review of the National Inpatient Database 2007-2013. PATIENT SAMPLE A total of 15,434,393 weighted hospital discharges. OUTCOME MEASURES Rates of PD, post-operative complications, length of stay (LOS), cost to charge (CCR), discharge location, and death. METHODS Inclusion criteria: elective orthopedic surgery procedures from 2007-2013 as defined by ICD-9-CM codes. Exclusion criteria: emergency, trauma, or non-elective surgery. Patients were grouped as shoulder, elbow, hand, spine, hip, knee, or foot/ankle. Descriptive statistics assessed demographics. Rates of DSM-IV PD, as classified by single-level CCS – diagnoses, and perioperative complications, were assessed for each orthopedic group.Logistic regression analysis assessed PD as a predictor of complications, extended LOS (LOS above 75th percentile), higher cost to charge ratio (CCR above 75th percentile), unfavorable discharge (not routine discharge), and death during hospitalization. RESULTS A total of 4,528,121/15,434,393 discharges (age: 61.02 ± 15.48, female: 57%, CCI: 0.91 ± 1.28) included in the analysis had PD. For all elective spine surgery patients, the overall rate of PD increased from 2007-2013 (32.3%, 33.8%, 34.6%, 37.1%, 37.2%, 39.1%, 40.7%, p CONCLUSIONS Psychiatric diagnoses have an immense impact on the treatment and outcomes of patients undergoing elective orthopedic procedures. Afflicted patients are more likely to have higher cost surgeries, extended length of stays, and death during their admission. More discussion is warranted on the possible utility of preoperative mental health treatment for these patients. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Extensive or persistent calcium phosphate deposition within soft tissues after severe traumatic injury or major orthopedic surgery can result in pain and loss of joint function. The pathophysiology of soft tissue calcification, including dystrophic calcification and heterotopic ossification (HO), is poorly understood; consequently, current treatments are suboptimal. Here, we show that plasmin protease activity prevents dystrophic calcification within injured skeletal muscle independent of its canonical fibrinolytic function. After muscle injury, dystrophic calcifications either can be resorbed during the process of tissue healing, persist, or become organized into mature bone (HO). Without sufficient plasmin activity, dystrophic calcifications persist after muscle injury and are sufficient to induce HO. Downregulating the primary inhibitor of plasmin (α2-antiplasmin) or treating with pyrophosphate analogues prevents dystrophic calcification and subsequent HO in vivo. Because plasmin also supports bone homeostasis and fracture repair, increasing plasmin activity represents the first pharmacologic strategy to prevent soft tissue calcification without adversely affecting systemic bone physiology or concurrent muscle and bone regeneration. © 2016 American Society for Bone and Mineral Research.

In an era of concern over the rising cost of health care, cost-effectiveness of auxiliary services merits careful evaluation. We compared costs and benefits of Helicopter Emergency Medical Service (HEMS) with Ground Emergency Medical Service (GEMS) in patients with an isolated ankle fracture. A medical record review was conducted for patients with an isolated ankle fracture who had been transported to a level 1 trauma center by either HEMS or GEMS from January 1, 2000 to December 31, 2010. We abstracted demographic data, fracture grade, complications, and transportation mode. Transportation costs were obtained by examining medical center financial records. A total of 303 patients was included in the analysis. Of 87 (28.71%) HEMS patients, 53 (60.92%) had sustained closed injuries and 34 (39.08%) had open injuries. Of the 216 (71.29%) GEMS patients, 156 (72.22%) had closed injuries and 60 (27.78%) had open injuries. No significant difference was seen between the groups regarding the percentage of patients with open fractures or the grade of the open fracture (p = .07). No significant difference in the rate of complications was found between the 2 groups (p = 18). The mean baseline cost to transport a patient via HEMS was $10,220 + a $108/mile surcharge, whereas the mean transport cost using GEMS was $976 per patient + $16/mile. Because the HEMS mode of emergency transport did not significantly improve patient outcomes, health systems should reconsider the use of HEMS for patients with isolated ankle fractures.

We compared types of complications leading to re-operations in open and closed distal tibia fractures treated by locking or nonlocking medial plates.Ninety-three patients from 2002 to 2012 who underwent open reduction and internal fixation (ORIF) and medial plating for distal extra-articular or partial articular tibia fractures were identified. Charts were retrospectively reviewed to determine the incidence of re-operation based on the type of complication that developed. Fisher's exact and chi-square tests were performed to analyze the incidence of complications based on injury and type of plate used.Thirty-three (35.5 %) patients required re-operations: 28.6 % (n = 16) with closed injuries had complications leading to re-operations compared with 45.9 % (n = 17) of patients with open injuries (p = 0.12). Patients with closed injuries were more likely to require re-operation due to hardware pain/prominence (p = 0.03), whereas patients with open injuries were more likely to require re-operation due to nonunion (p = 0.04). There were no significant differences in infection (p = 0.66) or malunion (p = 0.99) between groups. Locking plates showed higher costs but were not associated with decreased risk of re-operation.There was a high re-operation rate associated with distal tibia medial plating, with significant differences in the reason for re-operation between open versus closed groups. Complication rates were not influenced by the use of locking plates. Results of this study suggest that methods be considered to reduce re-operation based on type of fracture, such as early bone grafting or the use of alternate implants for open fractures.

Although recent literature has demonstrated the utility of the ASA score in predicting postoperative length of stay, complication risk and potential utilization of other hospital resources, the ASA score has been inconsistently assigned by anaesthesia providers. This study tested the reliability of assignment of the ASA score classification by both attending anaesthesiologists and anaesthesia residents specifically among the orthopaedic trauma patient population.Nine case-based scenarios were created involving preoperative patients with isolated operative orthopaedic trauma injuries. The cases were created and assigned a reference score by both an attending anaesthesiologist and orthopaedic trauma surgeon. Attending and resident anaesthesiologists were asked to assign an ASA score for each case. Rater versus reference and inter-rater agreement amongst respondents was then analyzed utilizing Fleiss's Kappa and weighted and unweighted Cohen's Kappa.Thirty three individuals provided ASA scores for each of the scenarios. The average rater versus reference reliability was substantial (Kw=0.78, SD=0.131, 95% CI=0.73-0.83). The average rater versus reference Kuw was also substantial (Kuw=0.64, SD=0.21, 95% CI=0.56-0.71). The inter-rater reliability as evaluated by Fleiss's Kappa was moderate (K=0.51, p.001). An inter-rater comparison within the group of attendings (K=0.50, p.001) and within the group of residents were both moderate (K=0.55, p.001). There was a significant increase in the level of inter-rater reliability from the self-reported 'very uncomfortable' participants to the 'very comfortable' participants (uncomfortable K=0.43, comfortable K=0.59, p.001).This study shows substantial agreement strength for reliability of the ASA score among anaesthesiologists when evaluating orthopaedic trauma patients. The significant increase in inter-rater reliability based on anaesthesiologists' comfort with the ASA scoring method implies a need for further evaluation of ASA assessment training and routine use on the ground. These findings support the use of the ASA score as a statistically reliable tool in orthopaedic trauma.