Risk of Subsequent Fusion After Isolated Decompression of Lumbar Facet Cysts.

INTRODUCTION: Lumbar facet cysts represent a potential source of nerve root compression in elderly patients. Isolated decompression without fusion has proven to be a reasonable treatment option in properly indicated patients. However, the risk of lumbar fusion after isolated decompression and facet cyst excision has yet to be elucidated. METHODS: The PearlDiver database was reviewed for patients undergoing isolated laminectomy for lumbar facet cyst from January 2015 to December 2018 using Current Procedural Terminology coding. Patients undergoing concomitant fusion or additional decompression, as well as those diagnosed with preexisting spondylolisthesis or without a minimum of 5-year follow-up, were excluded. Rates of subsequent lumbar fusion and potential risk factors for subsequent fusion were identified. Statistical analysis included descriptive statistics, chi square test, and multivariate logistic regression. Results were considered significant at P < 0.05. RESULTS: In total, 10,707 patients were ultimately included for analysis. At 5-year follow-up, 727 (6.79%) of patients underwent subsequent lumbar fusion after initial isolated decompression. Of these, 301 (2.81% of total patients, 41.4% of fusion patients) underwent fusion within the first year after decompression. Multivariate analysis identified chronic kidney disease, hypertension, and osteoarthritis as risk factors for requiring subsequent lumbar fusion at 5 years following the index decompression procedure ( P < 0.033; all). CONCLUSION: Patients undergoing isolated decompression for lumbar facet cysts undergo subsequent lumbar fusion at a 5-year rate of 6.79%. Risk factors for subsequent decompression include chronic kidney disease, hypertension, and osteoarthritis. This study will assist spine surgeons in appropriately counseling patients on expected postoperative course and potential risks of isolated decompression.

Reimbursement of Lumbar Fusion at an Orthopaedic Specialty Hospital Versus Tertiary Referral Center.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: To explore the differences in Medicare reimbursement for lumbar fusion performed at an orthopaedic specialty hospital (OSH) and a tertiary referral center and to elucidate drivers of Medicare reimbursement differences. SUMMARY OF BACKGROUND DATA: To provide more cost-efficient care, appropriately selected patients are increasingly being transitioned to OSHs for lumbar fusion procedures. There are no studies directly comparing reimbursement of lumbar fusion between tertiary referral centers (TRC) and OSHs. METHODS: Reimbursement data for a tertiary referral center and an orthopaedic specialty hospital were compiled through the Centers for Medicare and Medicaid Services. Any patient with lumbar fusions between January 2014 and December 2018 were identified. OSH patients were matched to TRC patients by demographic and surgical variables. Outcomes analyzed were reimbursement data, procedure data, 90-day complications and readmissions, operating room times, and length of stay (LOS). RESULTS: A total of 114 patients were included in the final cohort. The tertiary referral center had higher post-trigger ($13,554 vs. $8,541, P<0.001) and total episode ($49,973 vs. $43,512, P<0.010) reimbursements. Lumbar fusion performed at an OSH was predictive of shorter OR time (ß=0.77, P<0.001), shorter procedure time (ß=0.71, P<0.001), and shorter LOS (ß=0.53, P<0.001). There were no significant differences in complications (9.21% vs. 15.8%, P=0.353) or readmission rates (3.95% vs. 7.89%, P=0.374) between the 2 hospitals; however, our study is underpowered for complications and readmissions. CONCLUSION: Lumbar fusion performed at an OSH, compared with a tertiary referral center, is associated with significant Medicare cost savings, shorter perioperative times, decreased LOS, and decreased utilization of post-acute resources. LEVEL OF EVIDENCE: 3.

Does decompression adjacent to arthrodesis in the lumbar spine predispose patients to adjacent segment degeneration and disease: A retrospective analysis.

Background: The treatment for multi-level spinal stenosis in the setting of single-level instability is a common operative scenario for surgeons who treat degenerative lumbar spine pathology. However, there is conflicting evidence regarding the inclusion of adjacent "stable" levels in the arthrodesis construct because of the potential for iatrogenic instability placed on those segments with decompressive laminectomy alone. This study aims to determine whether decompression adjacent to arthrodesis in the lumbar spine is a risk factor for adjacent segment disease (AS Disease). Methods: A retrospective analysis identified consecutive patients over a three-year period who underwent single-level posterolateral lumbar fusion (PLF) in the setting of single or multi-level spinal stenosis. Patients were required to have a minimum of two-year follow-up. AS Disease was defined as the development of new radicular symptoms referable to a motion segment adjacent to the lumbar arthrodesis construct. The incidence of AS Disease and reoperation rates were compared between cohorts. Results: 133 patients met the inclusion criteria with an average follow-up of 54 months. Fifty-four patients had a PLF with adjacent segment decompression, and 79 underwent a single-segment decompression and PLF. 24.1% (13/54) of patients who had a PLF with adjacent level decompression developed AS Disease resulting in a 5.5% (3/54) reoperation rate. 15.2% (12/79) of patients who did not receive an adjacent level decompression developed AS Disease resulting in a reoperation rate of 7.5% (6/79). There was neither a significantly higher rate of AS Disease (p = 0.26) nor reoperation (p = 0.74) between the cohorts. Conclusions: Decompression adjacent to single-level PLF was not associated with an increased rate of AS Disease relative to single-level decompression and PLF.

Puncture Capsulotomy Technique for Hip Arthroscopy: Midterm Functional Outcomes.

Background: The most common surgical approaches in hip arthroscopy are interportal and T-capsulotomy. However, these methods may introduce capsular instability. Puncture capsulotomy preserves capsuloligamentous integrity by avoiding iatrogenic transection of the iliofemoral capsular ligament. Purpose: To present minimum 2-year functional outcomes for patients who underwent arthroscopic treatment for acetabular labral tears and concomitant femoroacetabular impingement using the puncture capsulotomy technique. Study Design: Case series; Level of evidence, 4. Methods: The authors conducted a retrospective review of prospectively collected data on patients who underwent arthroscopic acetabular labral tear treatment between December 2013 and May 2019. Included were patients aged ≥18 years who underwent hip arthroscopy by a single surgeon and completed a minimum of 2 years of patient-reported outcome measure (PROM) surveys. Intraoperatively, patients underwent hip arthroscopy via puncture capsulotomy to treat labral tears and any concomitant femoroacetabular impingement. Clinical outcome data consisted of PROMs. Results: A total of 163 hips were included; the mean patient follow-up was 30.4 months (range, 24-60 months; 95% CI, 28.5-32.3 months). Patients had a mean age of 37.9 years (range, 36.1-39.6 years), with a mean body mass index of 25.9 (range, 25.2-26.5). There were significant improvements in mean [95% CI] baseline to final follow-up scores for the 33-Item International Hip Outcome Tool (iHOT-33) (39.6 [36.8-42.4] vs 76.1 [72.7-79.6]), Hip Outcome Score-Activities of Daily Living (70.0 [67.0-73.0] vs 89.3 [87.3-91.3]), modified Harris Hip Score (60.1 [57.9-62.4] vs 84.9 [82.5-87.2]), and Hip Outcome Score-Sports Specific Subscale (41.8 [37.9-45.6] vs 75.7 [71.7-79.7]) (P < .001 for all). Additionally, the mean [95% CI] visual analog scale pain scores were noted to significantly improve throughout the duration of the postoperative period (from 6.3 [5.9-6.7] to 2.2 [1.8-2.6]; P < .001). There were no incidences of infection, avascular necrosis of the femoral head, dislocation/instability, or femoral neck fracture. At the 2-year follow-up, 81.0%, 62.0%, and 58.9% of hips achieved previously published clinically meaningful iHOT-33 thresholds for minimally clinically important difference, Patient Acceptable Symptom Score, and substantial clinical benefit, respectively. Conclusion: Puncture capsulotomy demonstrated significantly improved functional and clinically meaningful outcomes at a minimum 2-year follow-up, along with a minimal complication rate.

Risk stratification of patients undergoing outpatient lumbar decompression surgery.

BACKGROUND CONTEXT: Reimbursement has slowly transitioned from a fee-for-service model to a bundled payment model after introduction of the United States Centers for Medicare and Medicaid Services bundled payment program. To minimize healthcare costs, some surgeons are trying to minimize healthcare expenditures by transitioning appropriately selected lumbar decompression patients to outpatient procedure centers. PURPOSE: To prepare a risk stratification calculator based on machine learning algorithms to improve surgeon's preoperative predictive capability of determining whether a patient undergoing lumbar decompression will meet inpatient vs. outpatient criteria. Inpatient criteria was defined as any overnight hospital stay. STUDY DESIGN/SETTING: Retrospective single-institution cohort. PATIENT SAMPLE: A total of 1656 patients undergoing primary lumbar decompression. OUTCOME MEASURES: Postoperative outcomes analyzed for inclusion into the risk calculator included length of stay. METHODS: Patients were split 80-20 into a training model and a predictive model. This resulted in 1,325 patients in the training model and 331 into the predictive model. A logistic regression analysis ensured proper variable inclusion into the model. C-statistics were used to understand model effectiveness. An odds ratio and nomogram were created once the optimal model was identified. RESULTS: A total of 1,656 patients were included in our cohort with 1,078 dischared on day of surgery and 578 patients spending ≥ 1 midnight in the hospital. Our model determined older patients (OR=1.06, p<.001) with a higher BMI (OR=1.04, p<0.001), higher back pain (OR=1.06, p=.019), increasing American Society of Anesthesiologists (ASA) score (OR=1.39, p=.012), and patients with more levels decompressed (OR=3.66, p<0.001) all had increased risks of staying overnight. Patients who were female (OR=0.59, p=.009) and those with private insurance (OR=0.64, p=.023) were less likely to be admitted overnight. Further, weighted scores based on training data were then created and patients with a cumulative score over 118 points had a 82.9% likelihood of overnight. Analysis of the 331 patients in the test data demonstrated using a cut-off of 118 points accurately predicted 64.8% of patients meeting inpatient criteria compared to 23.0% meeting outpatient criteria (p<0.001). Area under the curve analysis showed a score greater than 118 predicted admission 81.4% of the time. The algorithm was incorporated into an open access digital application available here: https://rothmanstatisticscalculators.shinyapps.io/Inpatient_Calculator/?_ga=2.171493472.1789252330.1671633274-469992803.1671633274 CONCLUSIONS: Utilizing machine-learning algorithms we created a highly reliable predictive calculator to determine if patients undergoing outpatient lumbar decompression would require admission. Patients who were younger, had lower BMI, lower preoperative back pain, lower ASA score, less levels decompressed, private insurance, lived with someone at home, and with minimal comorbidities were ideal candidates for outpatient surgery.

Modified Frailty Index as a Predictor of Postoperative Complications and Patient-Reported Outcomes after Posterior Cervical Decompression and Fusion.

STUDY DESIGN: A retrospective cohort study. PURPOSE: To determine whether the 11-item modified frailty index (mFI) is associated with readmission rates, complication rates, revision rates, or differences in patient-reported outcome measures (PROMs) for patients undergoing posterior cervical decompression and fusion (PCDF). OVERVIEW OF LITERATURE: mFI incorporates preexisting medical comorbidities and dependency status to determine physiological reserve. Based on previous literature, it may be used as a predictive tool for identifying postoperative clinical and surgical outcomes. METHODS: Patients undergoing elective PCDF at our urban academic medical center from 2014 to 2020 were included. Patients were categorized by mFI scores (0-0.08, 0.09-0.17, 0.18-0.26, and ≥0.27). Univariate statistics compared demographics, comorbidities, and clinical/surgical outcomes. Multiple linear regression analysis evaluated the magnitude of improvement in PROMs at 1 year. RESULTS: A total of 165 patients were included and grouped by mFI scores: 0 (n=36), 0.09 (n=62), 0.18 (n=42), and ≥0.27 (n=30). The severe frailty group (mFI ≥0.27) was significantly more likely to be diabetic (p <0.001) and have a greater Elixhauser comorbidity index (p =0.001). They also had worse baseline Physical Component Score-12 (PCS-12) (p =0.011) and modified Japanese Orthopaedic Association (mJOA) (p =0.012) scores and worse 1-year postoperative PCS-12 (p =0.008) and mJOA (p =0.001) scores. On regression analysis, an mFI score of 0.18 was an independent predictor of greater improvement in ΔVisual Analog Scale neck (ß =-2.26, p =0.022) and ΔVAS arm (ß =-1.76, p =0.042). Regardless of frailty status, patients had similar 90-day readmission rates (p =0.752), complication rates (p =0.223), and revision rates (p =0.814), but patients with severe frailty were more likely to have longer hospital length of stay (p =0.006) and require non-home discharge (p <0.001). CONCLUSIONS: Similar improvements across most PROMs can be expected irrespective of the frailty status of patients undergoing PCDF. Complication rates, 90-day readmission rates, and revision rates are not significantly different when stratified by frailty status. However, patients with severe frailty are more likely to have longer hospital stays and require non-home discharge.

Management of C0 Sacral Fractures Based on the AO Spine Sacral Injury Classification: A Narrative Review.

The Arbeitsgemeinschaft fur Osteosynthese fragen Spine Sacral Injury Classification hierarchically separates fractures based on their injury severity with A-type fractures representing less severe injuries and C-type fractures representing the most severe fracture types. C0 fractures represent moderately severe injuries and have historically been referred to as nondisplaced "U-type" fractures. Injury management of these fractures can be controversial. Therefore, the purpose of this narrative review is to first discuss the Arbeitsgemeinschaft fur Osteosynthese fragen Spine Sacral Injury Classification System and describe the different fracture types and classification modifiers, with particular emphasis on C0 fracture types. The narrative review will then focus on the epidemiology and etiology of C0 fractures with subsequent discussion focused on the clinical presentation for patients with these injuries. Next, we will describe the imaging findings associated with these injuries and discuss the injury management of these injuries with particular emphasis on operative management. Finally, we will outline the outcomes and complications that can be expected during the treatment of these injuries.

MRSA Prophylaxis in Spine Surgery Decreases Postoperative Infections.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To compare infection rates before and after the implementation of a quality improvement protocol focused on methicillin-resistant Staphylococcus aureus (MRSA) screening and decolonization in patients undergoing lumbar fusion and/or decompression. SUMMARY OF BACKGROUND DATA: Prior studies have demonstrated MRSA infections comprise a sizable portion of SSIs. Additional studies are required to improve our understanding of the risks and benefits of MRSA decolonization with vancomycin prophylaxis. METHODS: A retrospective cohort analysis was conducted on patients who underwent spinal fusion or laminectomy before (2008-2011) and after (2013-2016) the implementation of an MRSA screening and treatment protocol. Odds ratios for MRSA, methicillin-sensitive Staphylococcus aureus (MSSA), and Vancomycin-resistant Enterococcus (VRE) infection before and after screening was calculated. Multivariate analysis assessed demographic characteristics as potential independent predictors of infection. RESULTS: A total of 8425 lumbar fusion and 2558 lumbar decompression cases met inclusion criteria resulting in a total cohort of 10,983 patients. There was a significant decrease in the overall rate of infections ( P <0.001), MRSA infections ( P <0.001), and MSSA infections ( P <0.001) after protocol implementation. Although VRE infections after protocol implementation were not significantly different ( P =0.066), VRE rates as a percentage of all postoperative infections were substantially increased (0 vs. 3.36%, P =0.007). On multivariate analysis, significant predictors of the infection included younger age (OR=0.94[0.92-0.95]), shorter length of procedure (OR=1.00[0.99-1.00]), spinal fusion (OR=18.56[8.22-53.28]), higher ASA class (OR=5.49[4.08-7.44]), male sex (OR=1.61[1.18-2.20]), and history of diabetes (OR=1.58[1.08-2.29]). CONCLUSION: The implemented quality improvement protocol demonstrated that preoperative prophylactically treating MRSA colonized patients decreased the rate of overall infections, MSSA infections, and MRSA infections. In addition, younger age, male sex, diabetic status, greater ASA scores, and spinal fusions were risk factors for postoperative infection.

Adult Isthmic Spondylolisthesis: A Radiographic and Outcomes Analysis Comparing Circumferential Fusions Versus TLIF Procedures.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The objective of this study was to compare radiographic and patient-reported outcome measures (PROMs) between circumferential fusions and transforaminal lumbar interbody fusion (TLIF) for adult isthmic spondylolisthesis (IS). SUMMARY OF BACKGROUND DATA: Definitive management of adult IS typically requires decompression and fusion. Multiple fusion techniques have been described, but literature is sparse in identifying the optimal technique. METHODS: Patients with IS undergoing single-level or 2-level circumferential fusion or TLIF with a minimum 1-year follow-up were included. Patient demographics, surgical characteristics, and PROMs were extracted from patients' electronic medical records. Descriptive statistics and multivariate regression analysis compared outcomes with significance set at P -value <0.05. RESULTS: A total of 78 circumferential fusions (48 open decompression and fusions and 30 circumferential fusions utilizing posterior percutaneous instrumentation) and 50 TLIF procedures were included. Length of stay was significantly longer when comparing circumferential procedures (3.56±0.96 d) versus TLIFs (2.88±1.14 d) ( P =0.002). The circumferential fusion group resulted in greater postoperative improvement in segmental lordosis [anterior/posterior (A/P): 6.45, TLIF: -1.99, P <0.001], posterior disk height (A/P: 12.6 mm, TLIF: 8.9 mm, P <0.001), and ∆disk height (A/P: 7.7 mm, TLIF: 3.6 mm, P <0.001). Both groups significantly improved in all PROMs ( P <0.001). While the circumferential fusion group had a significantly higher rate of perioperative surgical complications (12.82% vs. 2.00%, P =0.049), there was no difference in the rate of 30-day readmissions ( P =0.520) or revision surgeries between techniques ( P =0.057). CONCLUSIONS: Circumferential fusions are associated with improvements in radiographic outcomes compared with TLIFs, but this is at the expense of longer hospital length of stay and increased risk for perioperative complications. The surgical technique did not result in superior postoperative PROMs or differences in readmissions or revisions.

Dysphagia and Satisfaction Following Anterior Cervical Spine Surgery: A Prospective Observation Trial.

STUDY DESIGN: Prospective observation. OBJECTIVE: To assess the effect of dysphagia on patient satisfaction following anterior cervical discectomy and fusion. BACKGROUND: Difficulty with swallowing is a common complaint following anterior cervical spine surgery. The exact impact of this issue on the patient's overall satisfaction is unknown because of its often-transient nature. MATERIALS AND METHODS: A prospective evaluation of all patients from a single surgeon undergoing an anterior cervical spine surgery. Dysphagia was evaluated both preoperatively and postoperatively at set intervals via a combination of 3 validated scoring systems. Mean satisfaction scores at 6 months was evaluated at 6 months via modified CSRS survey. Comparative analysis was performed to determine if there was any relationship between the 2 outcomes. RESULTS: A total of 96.77% (68/71) of enrolled patients completed all of their follow-up surveys. The prevalence of dysphagia was 32.4% at 2 weeks after surgery, 20.6% at 6 weeks, 13.2% at 3 months, and 13.2% at 6 months. In total, 82.35% (56/68) of patients were satisfied with their surgical outcome and only 5.88% (4/68) were dissatisfied with their outcome. There was no relationship between a patient's overall satisfaction level and the presence of dysphagia at any postoperative interval. The absence of neck pain at 6 months was the only significant predictor of patient satisfaction (P=0.003). CONCLUSION: Dysphagia is a common but often transient complaint following anterior cervical spine surgery. Fortunately, its presence does not seem to correlate with a patient's overall satisfaction level following surgery. LEVEL OF EVIDENCE: Level I.

Cervical Alignment and Proximal and Distal Junctional Failure in Posterior Cervical Fusion: A Multicenter Comparison of 2 Surgical Approaches.

STUDY DESIGN: This was a multicenter retrospective cohort study. OBJECTIVE: The purpose of this study was to compare the surgical and radiographic outcomes of patients undergoing posterior cervical fusion (PCF) with constructs extending from C2 to T2 to patients with constructs extending from C3 to T1. SUMMARY OF BACKGROUND DATA: Limited evidence exists regarding the appropriate level of proximal and distal extension of PCF constructs. METHODS: A multicenter retrospective cohort study of patients who underwent PCF between 2012 and 2020 was performed. Surgical and radiographic outcomes were compared between those who had C3-T1 or C2-T2 constructs. RESULTS: A total of 155 patients were included in the study (C2-T2: 106 patients, C3-T1: 49 patients). There were no significant differences in demographics or preoperative symptoms between cohorts. Fusion rates were significantly higher in the C2-T2 (93%) than the C3-T1 (80%, P=0.040) cohort. When comparing the C2-T2 to the C3-T1 cohort, the C3-T1 cohort had a significantly greater rate of proximal junctional failure (2% vs. 10%, P=0.006), distal junctional failure (1% vs. 20%, P<0.001) and distal screw loosening (4% vs. 15%, P=0.02). Although ∆C2-C7 sagittal vertical axis increased significantly in both cohorts (C2-T2: 6.2 mm, P=0.04; C3-T1: 8.4 mm, P<0.001), correction did not significantly differ between groups (P=0.32). The C3-T1 cohort had a significantly greater increase in ∆C2 slope (8.0 vs. 3.1 degrees, P=0.03) and ∆C0-C2 Cobb angle (6.4 vs. 1.2 degrees, P=0.04). CONCLUSION: In patients undergoing PCF, a C2-T2 construct demonstrated lower rates of pseudarthrosis, distal junctional failure, proximal junctional failure, and compensatory upper cervical hyperextension compared with a C3-T1 construct.

Effect of a Mandatory Prescription Drug Monitoring Program on Patient-initiated Phone Calls After Spine Surgery.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The objective of this study was to determine the effect of a statewide, government-mandated prescription drug monitoring program (PDMP) on patient-initiated phone calls after lumbar and cervical spinal surgery. SUMMARY OF BACKGROUND DATA: Prior studies have examined the most common reasons for a postoperative phone calls, most of which pertain to pain or prescription medications. However, no studies have investigated the effects of mandatory opioid prescription reporting on these calls. METHODS: Patients who underwent lumbar decompression, lumbar fusion, or posterior cervical fusion were retrospectively identified. Patients were sorted into 1 of 2 cohorts based on their procedure date's relation to the initiation of the state's PDMP: "pre-PDMP" and "post-PDMP." All clinical and demographic data were obtained from electronic health records. Telephone communications from or on behalf of patients were retrospectively reviewed. Multivariable logistic regression was performed to determine independent factors associated with a postoperative phone call. RESULTS: Five hundred and twenty-five patients (2689 phone calls) were included in the study. Average number of phone calls per patient increased significantly after PDMP implementation among lumbar (3.27 vs. 5.18, P<0.001), cervical (5.08 vs. 11.67, P<0.001), and all (3.59 vs. 6.30, P<0.001) procedures. Age [odds ratio (OR): 1.05 (1.01, 1.09), P=0.02], cervical procedure [OR: 4.65 (1.93, 11.21), P=0.001], and a post-PDMP date of surgery [OR: 6.35 (3.55, 11.35), P<0.001] were independently associated with an increased likelihood of a postoperative phone call. A higher percentage of calls were in reference to postoperative care (4.6% vs. 2.4%, P=0.01) and wound care (4.3% vs. 1.4%, P<0.001) in the post-PDMP cohort compared with the pre-PDMP cohort. CONCLUSIONS: Patient-initiated telephone calls increased significantly after implementation of a mandatory statewide PDMP. Increasing age, operation involving the cervical spine, and surgery occurring after implementation of the state's PDMP were independently associated with an increased likelihood of postoperative phone call to health care providers.

The Effect of L5-S1 Degenerative Disc Disease on Outcomes of L4-L5 Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim was to investigate the clinical relevance of preoperative caudal adjacent segment degeneration (ASD) in patients undergoing isolated L4-5 fusion to determine a threshold of degeneration at which a primary L4-S1 fusion would be warranted. SUMMARY OF BACKGROUND DATA: Increased motion and biomechanical forces across the adjacent caudal segment in isolated L4-L5 fusion leads to concerns regarding the increased incidence of revision surgery because of the development of ASD. METHODS: Patients who underwent isolated L4-L5 fusion between 2014 and 2019 were reviewed. Pfirrmann grading and the disc heights of the caudal level relative to the rostral level were used to quantify preoperative adjacent degenerative disc disease. To assess the influence of preoperative caudal degenerative disc disease, preoperative disc height ratios (DHRs) were compared for patients who reported minimal, moderate, and severe Oswestry disability index (ODI) sores on postoperative assessment. For each patient-reported outcome measure (PROM), adjacent DDD was compared for those who did and did not meet MCID. An area under curve analysis was used to identify a threshold of degeneration impacting outcomes from the preoperative DHR. RESULTS: A total of 123 patients were studied with an average follow-up of 2.11 years. All patients demonstrated a significant improvement in all PROMs after surgery. When categorizing patients based on the severity of postoperative ODI scores, there were no preoperative differences in the L5-S1 Pfirrmann grading or DHRs. There was a significant association between greater preoperative anterior DHR and an increased number patients who met MCID for visual analog scale back. There were no radiographic differences in preoperative L5-S1 Pfirrmann grade or DHR for ODI, visual analog scale leg, MCS-12, or PCS-12. area under curve analysis was not able to identify a preoperative DHR threshold that reflected worse MCID for any PROM. CONCLUSION: No preoperative radiographic indicators of caudal ASD were predictive of worse clinical outcomes after isolated L4-5 fusion. LEVEL OF EVIDENCE: Level III.

Reimbursement of Lumbar Decompression at an Orthopedic Specialty Hospital Versus Tertiary Referral Center.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of this study was to investigate the differences in Medicare reimbursement for one- to three-level lumbar decompression procedures performed at a tertiary referral center versus an orthopedic specialty hospital (OSH). SUMMARY OF BACKGROUND DATA: Lumbar decompression surgery is one of the most commonly performed spinal procedures. Lumbar decompression also comprises the largest proportion of spinal surgery that has transitioned to the outpatient setting. METHODS: Patients who underwent a primary one- to three- level lumbar decompression were retrospectively identified. Reimbursement data for a tertiary referral center and an OSH were compiled through Centers for Medicare and Medicaid Services. Demographic data, surgical characteristics, and time cost data were collected through chart review. Multivariate regression models were used to determine independent factors associated with total episode of care cost, operating room (OR) time, procedure time, and length of stay (LOS), and to determine independent predictors of having the decompression performed at the OSH. RESULTS: Total episode of care, facility, and non-facility payments were significantly greater at the tertiary referral center than the OSH, as were OR time for one- to three-level procedures, procedure time of all pooled levels, and LOS for one- and two-level procedures. Three-level procedure was independently associated with increased OR time, procedure time, and LOS. Age and two-level procedure were also associated with increased LOS. Procedure at the OSH was associated with decreased OR time and LOS. Charlson Comorbidity Index was a negative predictor of decompression being performed in the OSH setting. CONCLUSION: Significant financial savings to health systems can be expected when performing lumbar decompression surgery at a specialty hospital as opposed to a tertiary referral center. Patients who are appropriate candidates for surgery in an OSH can in turn expect faster perioperative times and shorter LOS.Level of Evidence: 3.

Circumferential fusion with open versus percutaneous posterior fusion for lumbar isthmic spondylolisthesis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To investigate the clinical and radiographic differences between patients who underwent anterior lumber interbody fusion (ALIF) with either open or percutaneous posterior fusion for lumbar isthmic spondylolisthesis. SUMMARY OF BACKGROUND DATA: Circumferential fusion for isthmic spondylolisthesis is commonly performed with superior clinical outcomes, fusion rates, and restoration of sagittal balance when compared to posterior fusion alone. The outcomes comparing traditional open versus percutaneous posterior fusion in this setting have not been fully evaluated. METHODS: A retrospective review of patients who underwent ALIF with either traditional open or percutaneous posterior fusion for isthmic spondylolisthesis between 2014 and 2019 was conducted. Patient demographics, surgical characteristics, and radiographic and clinical outcomes were compared between groups. RESULTS: A total of 79 patients were included in the final analysis, with 49 in the Open group and 30 in the Percutaneous group. No differences were found with regard to demographic factors between groups including sex, body mass index (BMI), diabetic status, and smoking status. The percutaneous group had less estimated blood loss (EBL, 69.2 mL) and shorter length of stay (3.06 days) compared to the open group (446 mL, p = 0.017; 3.98 days, p = 0.003). Both groups demonstrated significant improvement in all clinical outcome measures after surgery (PCS-12, MCS-12, ODI, VAS Back, and VAS Leg scores). The percutaneous group achieved greater ∆VAS Back (Open = 3.55, Perc = 5.17; p = 0.045) and also had a significantly greater improvements in recovery ratio for VAS Back (Open: 0.43, Perc: 0.73; p = 0.037) and ODI (Open: 0.40, Perc = 0.67; p = 0.031). Regression analysis demonstrated percutaneous surgery to be significant predictor of superior improvement in VAS Back scores (ß = 1.957, p = 0.027). CONCLUSION: ALIF with percutaneous posterior fusion affords greater improvement in back pain and disability when compared to ALIF with open posterior fusion for isthmic spondylolisthesis. LEVEL OF EVIDENCE: III.

How Does the Presence of a Surgical Trainee Impact Patient Outcomes in Lumbar Fusion Surgery?

BACKGROUND: While the impact of trainee involvement in other surgical fields is well established, there is a paucity of literature assessing this relationship in orthopaedic spine surgery. The goal of this study was to further elucidate this relationship. METHODS: A retrospective cohort study was initiated on patients undergoing 1-3 level lumbar spine fusion at a single academic center. Operative reports from cases were examined, and patients were divided into 2 groups depending on whether a fellow or resident (F/R) or a physician's assistant (PA) was used as the primary assist. Patients with less than 1-year follow-up were excluded. Multiple linear regression was used to assess change in each patient-reported outcome, and multiple binary logistic regression was used to determine significant predictors of revision, infection, and 30- or 90-day readmission. RESULTS: One hundred and seventy-two patients were included in the F/R group compared with 178 patients in the PA group. No differences existed between groups for total surgery time, length of stay, 30- or 90-day readmissions, infection, or revision rates. No differences existed between groups in terms of patient-reported outcomes preoperatively or postoperatively. In addition, presence of a surgical trainee was not a significant predictor of patient outcomes or rates of infection, overall revision, or 30- and 90-day readmission rates. CONCLUSIONS: The results of this study indicate the presence of an orthopaedic spine F/R does not increase complication rates and does not affect short-term patient-reported outcomes in lumbar decompression and fusion surgery. LEVEL OF EVIDENCE: 3.

Hip Arthroscopy Versus Physical Therapy for the Treatment of Symptomatic Acetabular Labral Tears in Patients Older Than 40 Years: A Randomized Controlled Trial.

BACKGROUND: Previous observational studies have suggested poor results of arthroscopic surgery for the treatment of acetabular labral tears in patients older than 40 years. PURPOSE: To compare hip arthroscopy versus nonoperative management for symptomatic labral tears in patients older than 40 years who have limited radiographic osteoarthritis. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: In this single-surgeon, parallel randomized controlled trial, patients older than 40 years who had symptomatic, MRI-confirmed labral tears and limited radiographic osteoarthritis (Tönnis grades 0-2) were randomized 1:1 to arthroscopic surgery with postoperative physical therapy (SPT) or physical therapy alone (PTA) using an electronic randomization program. PTA patients who achieved unsatisfactory improvement were permitted to cross over to SPT after completing ≥14 weeks of physical therapy. The primary outcomes were International Hip Outcome Tool (iHOT-33) and modified Harris Hip Score (mHHS) at 12 months after randomization, and secondary outcomes included other patient-reported outcome measures and the visual analog scale. Outcomes were assessed at baseline and at 3, 6, and 12 months after randomization. Primary analysis was performed on an intention-to-treat basis using linear mixed-effect models. Sensitivity analyses included modified as-treated analysis and treatment-failure analysis. Due to infeasibility, patients and health care providers were both unblinded. RESULTS: The study enrolled 90 patients (46 [51.1%] SPT; 44 [48.9%] PTA); of these, 81 patients (42 [51.9%] SPT; 39 (48.1%) PTA) completed 12-month follow-up. A total of 28 of the 44 PTA patients crossed over to SPT within the study period (63.6% crossover). Intention-to-treat analysis revealed significantly greater iHOT-33 scores (+12.11; P = .007) and mHHS scores (+6.99 points; P = .04) in the SPT group than the PTA group at 12 months. Modified as-treated analysis revealed that these differences exceeded the minimal clinically important difference of 10.0 points (SPT-PTA iHOT-33, +11.95) and 8.0 points (SPT-PTA mHHS, +9.76), respectively. CONCLUSION: In patients older than 40 years with limited osteoarthritis, arthroscopic acetabular labral repair with postoperative physical therapy led to better outcomes than physical therapy alone. Thus, age over 40 years should not be considered a contraindication to arthroscopic acetabular labral repair. REGISTRATION: NCT03909178 (ClinicalTrials.gov identifier).

Does Cervical Spondylolisthesis Influence Patient-Reported Outcomes After Anterior Cervical Discectomy and Fusion Surgery?

BACKGROUND: No prior work has explored whether the presence of degenerative spondylolisthesis impacts patient-reported outcome measurements (PROMs) after an anterior cervical discectomy and fusion (ACDF); therefore, the goal of the current study was to determine whether the presence of a spondylolisthesis affects PROMs after an ACDF. METHODS: A retrospective cohort study was conducted on patients over the age of 18 who underwent a 1- or 2-level ACDF. All patients received preoperative standing lateral x-rays and were placed into 1 of 2 groups based on the presence of cervical spondylolisthesis from C2-T1: (1) no spondylolisthesis (NS) group or (2) spondylolisthesis (S) group. Preoperative, postoperative, and delta (postoperative minus preoperative) were recorded and compared between groups via univariate and multivariate analysis. Outcomes reported were the Physical Component Scores of the Short Form-12 (PCS-12), the Mental Component Scores of the Short Form-12 (MCS-12), the Neck Disability Index (NDI), and visual analog scale (VAS) Arm/Neck. RESULTS: A total of 202 patients were included in the final analysis with 154 in the NS group and 48 in the S group. Both patient cohorts reported significant postoperative improvement in PCS-12, NDI, and VAS Arm/Neck. When comparing outcome scores between groups, only MCS-12 delta scores were different between groups, with the S group exhibiting a greater mean delta score (8.3 vs 1.3, P = 0.024) than the NS group after ACDF. Multiple linear regression analysis indicated having spondylolisthesis at baseline was a significant predictor of greater change in MCS-12 than the NS group (ß = 4.841; 95% CI, 0.876, 8.805; P = 0.017). CONCLUSION: Both groups demonstrated significant postoperative improvement in PCS-12, NDI, or VAS Neck/Arm pain scores with no significant differences between groups. Patients with spondylolisthesis were found to have significantly greater improvement scores in MCS-12 scoring than those without spondylolisthesis after ACDF surgery.