An evaluation of fusion status following lumbar fusion surgery utilizing multi-planar computed tomography.

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

Relating preoperative MCS-12 to microdiscectomy outcomes.

PURPOSE: To determine the impact of poor mental health on patient-reported and surgical outcomes after microdiscectomy. METHODS: Patients ≥ 18 years who underwent a single-level lumbar microdiscectomy from 2014 to 2021 at a single academic institution were retrospectively identified. Patient-reported outcomes (PROMs) were collected at preoperative, three-month, and one-year postoperative time points. PROMs included the Oswestry Disability Index (ODI), Visual Analog Scale Back and Leg (VAS Back and VAS Leg, respectively), and the mental and physical component of the short form-12 survey (MCS and PCS). The minimum clinically important differences (MCID) were employed to compare scores for each PROM. Patients were categorized as having worse mental health or better mental health based on a MCS threshold of 50. RESULTS: Of 210 patients identified, 128 (61%) patients had a preoperative MCS score ≤ 50. There was no difference in 90-day surgical readmissions or spine reoperations within one year. At 3- and 12-month time points, both groups demonstrated improvements in all PROMs (p < 0.05). At three months postoperatively, patients with worse mental health had significantly lower PCS (42.1 vs. 46.4, p = 0.004) and higher ODI (20.5 vs. 13.3, p = 0.006) scores. Lower mental health scores were associated with lower 12-month PCS scores (43.3 vs. 48.8, p < 0.001), but greater improvements in 12-month ODI (- 28.36 vs. - 18.55, p = 0.040). CONCLUSION: While worse preoperative mental health was associated with lower baseline and postoperative PROMs, patients in both groups experienced similar improvements in PROMs. Rates of surgical readmissions and reoperations were similar among patients with varying preoperative mental health status.

Values derived from patient reported outcomes in spine surgery: a systematic review of the minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state.

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

The severity of preoperative anemia escalates risk of poor short-term outcomes after lumbar spine fusion.

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

The impact of cage positioning on lumbar lordosis and disc space restoration following minimally invasive lateral lumbar interbody fusion.

OBJECTIVE: The objective of this study was to evaluate patient and surgical factors that predict increased overall lumbar lordosis (LL) and segmental lordosis correction following a minimally invasive lateral lumbar interbody fusion (LLIF) procedure. METHODS: A retrospective review was conducted of all patients who underwent one- or two-level LLIF. Preoperative, initial postoperative, and 6-month postoperative measurements of LL, segmental lordosis, anterior disc height, and posterior disc height were collected from standing lateral radiographs for each patient. Cage placement was measured utilizing the center point ratio (CPR) on immediate postoperative radiographs. Spearman correlations were used to assess associations between cage lordosis and radiographic parameters. Multivariate linear regression was performed to assess independent predictors of outcomes. RESULTS: A total of 106 levels in 78 unique patients were included. Most procedures involved fusion of one level (n = 50, 64.1%), most commonly L3-4 (46.2%). Despite no differences in baseline segmental lordosis, patients with anteriorly or centrally placed cages experienced the greatest segmental lordosis correction immediately (mean anterior 4.81° and central 4.46° vs posterior 2.47°, p = 0.0315) and at 6 months postoperatively, and patients with anteriorly placed cages had greater overall lordosis correction postoperatively (mean 6.30°, p = 0.0338). At the 6-month follow-up, patients with anteriorly placed cages experienced the greatest increase in anterior disc height (mean anterior 6.24 mm vs posterior 3.69 mm, p = 0.0122). Cages placed more posteriorly increased the change in posterior disc height postoperatively (mean posterior 4.91 mm vs anterior 1.80 mm, p = 0.0001) and at 6 months (mean posterior 4.18 mm vs anterior 2.06 mm, p = 0.0255). There were no correlations between cage lordotic angle and outcomes. On multivariate regression, anterior cage placement predicted greater 6-month improvement in segmental lordosis, while posterior placement predicted greater 6-month improvement in posterior disc height. Percutaneous screw placement, cage lordotic angle, and cage height did not independently predict any radiographic outcomes. CONCLUSIONS: LLIF procedures reliably improve LL and increase intervertebral disc space. Anterior cage placement improves the lordosis angle greater than posterior placement, which better corrects sagittal alignment, but there is still a significant improvement in lordosis even with a posteriorly placed cage. Posterior cage placement provides greater restoration in posterior disc space height, maximizing indirect decompression, but even the anteriorly placed cages provided indirect decompression. Cage parameters including cage height, lordosis angle, and material do not impact radiographic improvement.

Preoperative epidural steroid injections do not increase the risk of postoperative infection in patients undergoing lumbar decompression or fusion: a systematic review and meta-analysis.

PURPOSE: Epidural corticosteroid injections (ESI) are a mainstay of nonoperative treatment for patients with lumbar spine pathology. Recent literature evaluating infection risk following ESI after elective orthopedic surgery has produced conflicting evidence. Our primary objective was to review the literature and provide a larger meta-analysis analyzing the temporal effects of steroid injections on the risk of infection following lumbar spine surgery. METHODS: We conducted a query of the PubMed, Embase, and Scopus databases from inception until April 1, 2022 for studies evaluating the risk of infection in the setting of prior spinal steroid injections in patients undergoing lumbar spine decompression or fusion. Three meta-analyses were conducted, (1) comparing ESI within 30-days of surgery to control, (2) comparing ESI within 30-days to ESI between 1 and 3 months preoperatively, and (3) comparing any history of ESI prior to surgery to control. Tests of proportions were utilized for all comparisons between groups. Study heterogeneity was assessed via forest plots, and publication bias was assessed quantiatively via funnel plots and qualitatively with the Newcastle-Ottawa Scale. RESULTS: Nine total studies were included, five of which demonstrated an association between ESI and postoperative infection, while four found no association. Comparison of weighted means demonstrated no significant difference in infection rates between the 30-days ESI group and control group (2.67% vs. 1.69%, p = 0.144), 30-days ESI group and the > 30-days ESI group (2.34% vs. 1.66%, p = 0.1655), or total ESI group and the control group (1.99% vs. 1.70%, p = 0.544). Heterogeneity was low for all comparisons following sensitivity analyses. CONCLUSION: Current evidence does not implicate preoperative ESI in postoperative infection rates following lumbar fusion or decompression. Operative treatment should not be delayed due to preoperative steroid injections based on current evidence. There remains a paucity of high-quality data in the literature evaluating the impact of preoperative ESI on postoperative infection rates. LEVEL OF EVIDENCE: II.

Evidence and Controversies in Geriatric Odontoid Fracture Management.

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

Cellular Bone Matrix in Spine Surgery - Are They Worth the Risk: A Systematic Review.

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

Subfascial Lumbar Spine Drain Output Does Not Affect Outcomes After Incidental Durotomies in Elective Spine Surgery.

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

The Surgical Algorithm for the AO Spine Sacral Injury Classification System.

STUDY DESIGN: Global cross-sectional survey. OBJECTIVE: To establish a surgical algorithm for sacral fractures based on the Arbeitsgemeinschaft für Osteosynthesefragen (AO) Spine Sacral Injury Classification System. SUMMARY OF BACKGROUND DATA: Although the AO Spine Sacral Injury Classification has been validated across an international audience of surgeons, a consensus on a surgical algorithm for sacral fractures using the Sacral AO Spine Injury Score (Sacral AOSIS) has yet to be developed. METHODS: A survey was sent to general orthopedic surgeons, orthopedic spine surgeons, and neurosurgeons across the five AO spine regions of the world. Descriptions of controversial sacral injuries based on different fracture subtypes were given, and surgeons were asked whether the patient should undergo operative or nonoperative management. The results of the survey were used to create a surgical algorithm based on each subtype's sacral AOSIS. RESULTS: An international agreement of 70% was decided on by the AO Spine Knowledge Forum Trauma experts to indicate a recommendation of initial operative intervention. Using this, sacral fracture subtypes of AOSIS 5 or greater were considered operative, while those with AOSIS 4 or less were generally nonoperative. For subtypes with an AOSIS of 3 or 4, if the sacral fracture was associated with an anterior pelvic ring injury (M3 case-specific modifier), intervention should be left to the surgeons' discretion. CONCLUSION: The AO Spine Sacral Injury Classification System offers a validated hierarchical system to approach sacral injuries. Through multispecialty and global surgeon input, a surgical algorithm was developed to determine appropriate operative indications for sacral trauma. Further validation is required, but this algorithm provides surgeons across the world with the basis for discussion and the development of standards of care and treatment.

Implementation of a Private Payer Bundled Payment Model While Maintaining High-Value Lumbar Spinal Fusion.

STUDY DESIGN: Retrospective single-institution cohort. OBJECTIVE: To evaluate the implementation of a commercial bundled payment model in patients undergoing lumbar spinal fusion. SUMMARY OF BACKGROUND DATA: BPCI-A caused significant losses for many physician practices, prompting private payers to establish their own bundled payment models. The feasibility of these private bundles has yet to be evaluated in spine fusion. METHODS: Patients undergoing lumbar fusion from October to December 2018 in BPCI-A before our institution's departure were included for BPCI-A analysis. Private bundle data was collected from 2018 to 2020. Analysis of the transition was conducted among Medicare-aged beneficiaries. Private bundles were grouped by calendar year (Y1, Y2, Y3). Stepwise multivariate linear regression was performed to measure independent predictors of net deficit. RESULTS: The net surplus was the lowest in Y1 ($2,395, P =0.03) but did not differ between our final year in BPCI-A and subsequent years in private bundles (all, P >0.05). AIR and SNF patient discharges decreased significantly in all private bundle years compared with BPCI. Readmissions fell from 10.7% (N=37) in BPCI-A to 4.4% (N=6) in Y2 and 4.5% (N=3) Y3 of private bundles ( P <0.001). Being in Y2 or Y3 was independently associated with a net surplus in comparison to the Y1 (ß: $11,728, P =0.001; ß: $11,643, P =0.002). Postoperatively, length of stay in days (ß: $-2,982, P <0.001), any readmission (ß: -$18,825, P =0.001), and discharge to AIR (ß: $-61,256, P <0.001) or SNF (ß: $-10,497, P =0.058) were all associated with a net deficit. CONCLUSIONS: Nongovernmental bundled payment models can be successfully implemented in lumbar spinal fusion patients. Constant price adjustment is necessary so bundled payments remain financially beneficial to both parties and systems overcome early losses. Private insurers who have more competition than the government may be more willing to provide mutually beneficial situations where cost is reduced for payers and health systems. LEVEL OF EVIDENCE: 3.

In-hospital mortality trends after surgery for traumatic thoracolumbar injury: A national inpatient sample database study.

Introduction: Given the increasing incidence of traumatic thoracolumbar injuries in recent years, studies have sought to investigate potential risk factors for outcomes in these patients. Research question: The aim of this study was to investigate trends and risk factors for in-hospital mortality after fusion for traumatic thoracolumbar injury. Materials and methods: Patients undergoing thoracolumbar fusion after traumatic injury were queried from the National Inpatient Sample (NIS) from 2012 to 2017. Analysis was performed to identify risk factors for inpatient mortality after surgery. Results: Patients in 2017 were on average older (51.0 vs. 48.5, P = 0.004), had more admitting diagnoses (15.5 vs. 10.7, p < 0.001), were less likely to be White (75.8% vs. 81.2%, p = 0.006), were from a ZIP code with a higher median income quartile (Quartile 1: 31.4% vs. 28.6%, p = 0.011), and were more likely to have Medicare as a primary payer (22.9% vs. 30.1%, p < 0.001). Bivariate analysis of demographics and surgical characteristics demonstrated that patients in the in-hospital mortality group (n = 90) were older (70.2 vs. 49.6, p < 0.001), more likely to be male (74.4% vs. 62.8%, p = 0.031), had a great number of admitted diagnoses (21.3 vs. 12.7, p < 0.001), and were more likely to be insured by Medicare (70.0% vs. 27.0%, p < 0.001). Multivariate regression analysis found age (OR 1.06, p < 0.001) and Black race (OR 3.71, p = 0.007) were independently associated with in-hospital mortality. Conclusion: Our study of nationwide, traumatic thoracolumbar fusion procedures from 2012 to 2017 in the NIS database found older, black patients were at increased risk for in-hospital mortality after surgery.

A Longitudinal Evaluation of Coronavirus Disease 2019 and Its Effects on Spinal Decompressions With or Without Fusion.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: The objectives were to (1) compare the safety of spine surgery before and after the emergence of coronavirus disease 2019 (COVID-19) and (2) determine whether patients with a history of COVID-19 were at increased risk of adverse events. SUMMARY AND BACKGROUND DATA: The COVID-19 pandemic had a tremendous impact on several health care services. In spine surgery, elective cases were canceled and patients received delayed care due to the uncertainty of disease transmission and surgical outcomes. As new coronavirus variants arise, health care systems require guidance on how to provide optimal patient care to all those in need of our services. PATIENTS AND METHODS: A retrospective review of patients undergoing spine surgery between January 1, 2019 and June 30, 2021 was performed. Patients were split into pre-COVID or post-COVID cohorts based on local government guidelines. Inpatient complications, 90-day readmission, and 90-day mortality were compared between groups. Secondary analysis included multiple logistic regression to determine independent predictors of each outcome. RESULTS: A total of 2976 patients were included for analysis with 1701 patients designated as pre-COVID and 1275 as post-COVID. The pre-COVID cohort had fewer patients undergoing revision surgery (16.8% vs 21.9%, P < 0.001) and a lower home discharge rate (84.5% vs 88.2%, P = 0.008). Inpatient complication (9.9% vs 9.2%, P = 0.562), inpatient mortality (0.1% vs 0.2%, P = 0.193), 90-day readmission (3.4% vs 3.2%, P = 0.828), and 90-day mortality rates (0.8% vs 0.8%, P = 0.902) were similar between groups. Patients with positive COVID-19 tests before surgery had similar complication rates (7.7% vs 6.1%, P = 1.000) as those without a positive test documented. CONCLUSIONS: After the emergence of COVID-19, patients undergoing spine surgery had a greater number of medical comorbidities, but similar rates of inpatient complications, readmission, and mortality. Prior COVID-19 infection was not associated with an increased risk of postsurgical complications or mortality. LEVEL OF EVIDENCE: Level III.

Evaluation of perioperative care and drivers of cost in geriatric thoracolumbar trauma.

Introduction: As the population of elderly patients continues to rise, the number of these individuals presenting with thoracolumbar trauma is expected to increase. Research question: To investigate thoracolumbar fusion outcomes for patients with vertebral fractures as stratified by decade. Secondarily, we examined the variability of cost across age groups by identifying drivers of cost of care. Materials and methods: We queried the United States Nationwide Inpatient Sample(NIS) for adult patients undergoing spinal fusion for thoracolumbar fractures between 2012 and 2017. Patients were stratified by decade 60-69(sexagenarians), 70-79(septuagenarians) and 80-89(octogenarians). Bivariable analysis followed by multivariable regression was performed to assess independent predictors of length of stay(LOS), hospital cost, and discharge disposition. Results: A total of 2767 patients were included, of which 46%(N = 1268) were sexagenarians, 36% septuagenarians and 18%(N = 502) octogenarians. Septuagenarians and octogenarians had shorter LOS compared to sexagenarians(ß = -0.88 days; p = 0.012) and(ß = -1.78; p < 0.001), respectively. LOS was reduced with posterior approach(-2.46 days[95% CI: 3.73-1.19]; p < 0.001), while Hispanic patients had longer LOS(+1.97 [95% CI: 0.81-3.13]; p < 0.001). Septuagenarians had lower total charges $12,185.70(p = 0.040), while the decrease in charges in octogenarians was more significant, with a decrease of $26,016.30(p < 0.001) as compared to sexagenarians. Posterior approach was associated with a decrease of $24,337.90 in total charges(p = 0.026). Septuagenarians and octogenarians had 1.72 higher odds(p < 0.001) and 4.16 higher odds(p < 0.001), respectively, of discharge to a skilled nursing facility. Discussion and conclusions: Healthcare utilization in geriatric thoracolumbar trauma is complex. Cost reductions in the acute hospital setting may be offset by unaccounted costs after discharge. Further research into this phenomenon and observed racial/ethnic disparities must be pursued.

The Impact of Socioeconomic Status on the Presence of Advance Care Planning Documents in Patients With Acute Cervical Spinal Cord Injury.

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

The Role of L1PA in Patient-reported Outcomes in Patients Undergoing Single-level Lumbar Fusion for Degenerative Spondylolisthesis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine whether the L1 pelvic angle (L1PA) can be used to predict quality of life outcomes for adults one year after L4-L5 fusion to treat degenerative spondylolisthesis. SUMMARY OF BACKGROUND DATA: L1PA is beneficial in the evaluation of preoperative and postoperative quality of life outcomes in patients undergoing surgery for spinal deformity. No studies have examined its utility in surgical patients with degenerative spinal disease. METHODS: Patients undergoing L4-L5 posterolateral decompression and fusion or transforaminal lumbar interbody fusion for degenerative lumbar spondylolisthesis were grouped by preoperative and postoperative L1PA, and further stratified by cut offs of >7.2° and <7.2° based on previous literature. We also stratified patients by presence of an ideal calculated L1PA, defined as (0.5×Pelvic incidence) -21 +/-5°, as proposed by prior literature. Preoperative, one-year postoperative and Δ (postoperative minus preoperative) patient-reported outcome measures (PROMs) and radiographic measurements were collected. RESULTS: Twenty-four patients were identified with preoperative L1PAs <7.2° and 132 with L1PAs >7.2°. Eighteen patients were identified with postoperative L1PAs <7.2° and 138 with L1PAs>7.2°. Sixty-five and fifty-seven patients were identified as having ideal calculated preoperative and postoperative L1PAs, respectively. When using absolute cutoffs, L1PA correlated with pelvic tilt, pelvic incidence, and pelvic incidence-lumbar lordosis mismatch (PI-LL). When using calculated L1PAs, L1PA correlated with lumbar lordosis, PI-LL, pelvic tilt and sacral slope. With respect to PROMs, no statistically significant differences existed between cohorts both preoperatively and at one-year postoperatively on either univariate and multivariate analyses. CONCLUSION: L1PA may be a helpful radiographic consideration that translates to clinically relevant outcomes in spinal deformity. However, it does not appear as predictive of patient outcomes after single-level fusion for patients with L4-L5 degenerative spondylolisthesis. Further studies are warranted to investigate the role of L1PA in degenerative spine patients.

Impact of the Prognostic Nutritional Index on Outcomes in Native Spine Infection.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The objective of this study was to determine if baseline prognostic nutritional index (PNI) score could be used to predict outcomes in patients with native spine infections, including the need for operative intervention. SUMMARY OF BACKGROUND DATA: Nutritional status is an important, potentially modifiable risk factor, to consider in the native spine population. The prognostic nutritional index (PNI) score is a tool that has demonstrated utility as a marker of preoperative nutritional status in patients undergoing surgery, however it has not yet been studied in the context of native spine infection. METHODS: Adult patients (≥18 y) with a diagnosis of spine infection from 2017-2022 were retrospectively identified. Native spine infection was defined as a diagnosis of spinal infection in the absence of prior spine surgery within 3 months of diagnosis. PNI was calculated using the equation: PNI = 10 * serum albumin (g/dL) + 0.005 Total Lymphocyte Count (/µL. Patients were stratified into high or low PNI groups based on their PNI being above or below the average, respectively. RESULTS: There were 45 patients in the low PNI group and 56 patients in the high PNI group. Patients in the low PNI group were more likely to require surgery (P=0.046), had more levels decompressed (P=0.012), and were more likely to undergo two or more irrigation & debridement procedures (P=0.016). Patients in the low PNI group were also less likely to be discharged home (P=0.016). There was no difference in length of stay, inpatient complications, 90-day readmissions, 90-day ED visits, or 1-year reoperations between groups. CONCLUSION: While post-admission outcomes and inpatient complications were similar across PNI groups, PNI on admission provides useful insight into the severity of infection and predicts the need for operative intervention in patients presenting with native spine infection.

Immediate vs. delayed venous thromboembolism prophylaxis following spine surgery: increased rate of unplanned reoperation for postoperative hematoma with immediate prophylaxis.

BACKGROUND CONTEXT: There is significant variability in postoperative chemoprophylaxis protocols amongst spine providers due to perceived risks and benefits, but limited data on the topic. At our institution, both orthopaedic spine and neurosurgery departments utilize unfractionated subcutaneous heparin in identical dosages and frequency, with the only difference being time to initiation postoperatively. PURPOSE: To evaluate the rate of symptomatic venous thromboembolism (VTEs) and unplanned reoperation for hematoma based on timing of chemoprophylaxis initiation. STUDY DESIGN/SETTING: Single institution retrospective cohort study. PATIENT SAMPLE: Patients undergoing elective spine surgery, excluding patients undergoing surgery in the setting of trauma, malignancy, or infection OUTCOME MEASURES: Outcome measures included the diagnosis of a venous thromboembolism within 90 days of surgery and unplanned reoperation for a hematoma METHODS: Patients undergoing elective spine surgery from 2017 to 2021 were grouped based on chemoprophylaxis protocol. In the "immediate" group, patients received subcutaneous heparin 5000 units every 8 hours starting immediately after surgery, and in the "delayed" group, patients received chemoprophylaxis starting postoperative day (POD)-2 for any decompressions and/or fusions involving a spinal cord level (i.e., L2 and above) and POD-1 for those involving only levels below the spinal cord (i.e., L3 to pelvis). A cox proportional hazards model was created to assess independent predictors of venous thromboembolic events, while a logistic regression was utilized for unplanned reoperations for hematoma. RESULTS: Of 8,704 patients, a total of 98 (1.13%) VTE events occurred, of which 43 (0.49%) were pulmonary embolism. Fifty-four patients (0.62%) had unplanned reoperations for postoperative hematomas. On cox proportional hazards model analysis, immediate chemoprophylaxis was not protective of a venous thromboembolism (Hazard Ratio: 1.18, p=.436), but, it was a significant independent predictor for unplanned reoperation for hematoma on multivariable logistic regression modeling (Odds Ratio: 3.29, p<.001). CONCLUSIONS: Both chemoprophylaxis protocols in our study resulted in low rates of VTE and postoperative hematoma. However, our findings suggest that the delayed chemoprophylaxis protocol may mitigate postoperative hematoma formation without increasing the risk for a thrombotic event.

The Impact of Outpatient Physical Therapy on Patient-Reported Outcomes After Lumbar Fusion: Perspective from A Bundled Care Dataset.

OBJECTIVE/BACKGROUND: As value-based care grows in popularity across the United States, more payers have turned toward bundled payment models for surgical procedures. Though episode costs in spine are highly variable, physical therapy (PT) has been identified as a driver of 90-day cost. The goal of this study is to assess the impact of postoperative PT on patient-reported outcomes and cost after lumbar fusion surgery using bundled insurance data. METHODS: Bundled payment information of lumbar fusion episodes-of-care (EOC) from 2019 to 2021 was reviewed at a single, urban, tertiary care center. EOC comprised a 210-day period surrounding the date of the procedure, beginning 30 days preoperatively and ending 180 days postoperatively. Patients were grouped into physical therapy (PT) and no physical therapy (no PT) groups based on the presence of PT claims. RESULTS: Bivariate analysis of surgical outcomes revealed similar overall complication rates (P = 0.413), 30-day readmissions (P = 0.366), and 90-day readmissions (P = 0.774). Patients who did not participate in postoperative PT had significantly better preoperative physical component score (PCS) (P = 0.003), 6-month postoperative PCS (P = 0.001), and 6-month ΔPCS (P = 0.026) compared with patients who participated in postoperative PT. At 1-year follow-up, patients who did not participate in PT had less leg pain (P = 0.041) than those who did participate in PT. CONCLUSIONS: Our study finds that PT after lumbar fusion is not associated with significant improvement in Oswestry Disability Index, PCS, mental component score, or visual analog scale pain scores. Additionally, the number of PT sessions a patient attends has no correlation with improvement in these outcomes.

One year patient reported outcomes after single-level lumbar fusion at orthopedic specialty hospital compared to tertiary referral center.

BACKGROUND CONTEXT: Lumbar spinal fusion is an increasingly common operation to treat symptoms related to degenerative disorders of the spine including radiculopathy and pain. As the volume of spine surgeries grows, it is becoming increasingly common for procedures to take place in nontertiary care centers, including orthopaedic specialty hospitals (OSH). While previous research demonstrates that surgical outcomes at an OSH are noninferior to those at a tertiary referral center (TRC), the implications of this difference on patient-reported outcome measures (PROMs) have not been sufficiently assessed. PURPOSE: The objectives of this study were (1) to determine if changes in patient reported outcome measures (PROMs) after elective lumbar spinal fusion surgery differ between patients who undergo surgery at an orthopedic specialty hospital (OSH) and those who undergo surgery at a tertiary referral center (TRC) and (2) to characterize differences in short-term outcomes between hospitals. STUDY DESIGN: Retrospective cohort study. PATIENT SAMPLE: Adult patients (≥18 years old) who underwent primary, elective single-level posterior lumbar decompression and fusion between January 2014 and December 2021 at a tertiary referral center or an orthopaedic specialty hospital. OUTCOME MEASURES: PROMs: Oswestry Disability Index (ODI), Short-form 12 (SF12) Mental Component Summary (MCS); SF12 Physical Component Summary (PCS); Visual Analogue Back and Leg (VAS Back/Leg) METHODS: PROMs were collected preoperatively, 6 months after surgery, and 1 year after surgery. Six-month and 1-year delta PROM values were calculated by subtracting the preoperative PROM score from the 6-month or 1-year score, respectively. Multivariable linear regression analyses were conducted to assess the independent effect of hospital location on postoperative PROM scores. RESULTS: A total of 288 patients were identified as part of the study cohort including 205 patients who underwent surgery at the tertiary hospital and 83 patients who underwent surgery at the OSH. OSH patients had shorter length of stay (1.57±0.72 vs. 3.28±1.32, p<.001), however there was no difference in discharge disposition or 90-day readmission rates between hospitals (p>.05). At 6 months, having surgery at the specialty hospital was associated with higher PCS (estimate=2.96, confidence interval: 0.21-5.71, p=.035). At 1-year postoperatively, the location of surgery no longer demonstrated significant associations with PROM scores. Preoperative PROM scores demonstrated significant associations with 6-month and 1-year scores for each PROM (p<.05) except VAS leg at 6 months postoperatively. CONCLUSION: To our knowledge, this is one of the largest studies investigating PROMs at OSH versus TRCs for single-level lumbar fusions. We demonstrated that at 1-year follow-up, there is not a significant difference in PROM improvement between patients who undergo surgery at a TRC and patients who do so at an OSH.