Postoperative opioid consumption patterns diverge between propensity matched patients undergoing traumatic and elective cervical spine fusion.

BACKGROUND CONTEXT: Prolonged opioid therapy following spine surgery is an ongoing postoperative concern. While prior studies have investigated postoperative opioid use patterns in the elective cervical surgery patient population, to our knowledge, opioid use patterns in patients undergoing surgery for traumatic cervical spine injuries have not been elucidated. PURPOSE: The purpose of this study was to compare opioid use and prescription patterns in the postoperative pain management of patients undergoing traumatic and elective cervical spine fusion surgery. STUDY DESIGN: Retrospective cohort study. PATIENT SAMPLE: Adult patients with traumatic cervical injuries who underwent primary anterior cervical discectomy and fusion (ACDF) or posterior cervical decompression and fusion (PCDF) during their initial hospital admission. The propensity matched, control group consisted of adult elective cervical fusion patients who underwent primary ACDF or PCDF. OUTCOME MEASURES: Demographic data, surgical characteristics, spinal disease diagnosis, location of cervical injury, procedure type, operative levels fused, and Prescription Drug Monitoring Program (PDMP) data. PDMP data included the number of opioid prescriptions filled, preoperative opioid use, postoperative opioid use, and use of perioperative benzodiazepines, muscle relaxants, or gabapentin. Opioid consumption data was collected in morphine milligram equivalents (MME) and standardized per day. METHODS: A 1:1 propensity match was performed to match traumatic injury patients undergoing cervical fusion surgery with elective cervical fusion patients. Traumatic injury patients were matched based on age, sex, CCI, procedure type, and cervical levels fused. Pre- and postoperative opioid, benzodiazepine, muscle relaxant, and gabapentin use were assessed for the traumatic injury and elective patients. T- or Mann-Whitney U tests were used to compare continuous data and Chi-Squared or Fisher's Exact were used to compare categorical data. Multivariate stepwise regression using MME per day 0 - 30 days following surgery as the dependent outcome was performed to further evaluate associations with postoperative opioid use. RESULTS: A total of 48 patients underwent fusion surgery for a traumatic cervical spine injury and 48 elective cervical fusion with complete PDMP data were assessed. Elective patients were found to fill more prescriptions (3.19 vs. 0.65, p=.023) and take more morphine milligram equivalents (MME) per day (0.60 vs. 0.04, p=.014) within 1 year prior to surgery in comparison to traumatic patients. Elective patients were also more likely to use opioids (29.2% vs. 10.4%, p=.040) and take more MMEs per day (0.70 vs. 0.05, p=.004) within 30 days prior to surgery. Within 30 days postoperatively, elective patients used opioids more frequently (89.6% vs. 52.1%, p<.001) and took more MMEs per day (3.73 vs. 1.71, p<.001) than traumatic injury patients. Multivariate stepwise regression demonstrated preoperative opioid use (Estimate: 1.87, p=.013) to be correlated with higher postoperative MME per day within 30 days of surgery. Surgery after traumatic injury was correlated with lower postoperative MME use per day within 30 days of surgery (Estimate: -1.63 p=.022). CONCLUSION: Cervical fusion patients with a history of traumatic spine injury consume fewer opioids in the early postoperative period in comparison to elective cervical fusion patients, however both cohorts consumed a similar amount after the initial 30-day postoperative period. Preoperative opioid use was also a risk factor for higher consumption in the short-term postoperative period. These results may aid physicians in further understanding patients' postoperative care needs based on presenting injury characteristics and highlights the need for enhanced follow-up care for traumatic cervical spine injury patients after fusion surgery.

A Comparison of Clinical Outcomes Between Anterior Cervical Discectomy and Fusion Versus Posterior Cervical Laminoplasty for Multilevel Cervical Myelopathy.

STUDY DESIGN: Retrospective Cohort. OBJECTIVE: To compare patient-reported outcomes and surgical outcomes after anterior cervical discectomy and fusion (ACDF) versus cervical laminoplasty for multilevel cervical spondylotic myelopathy. BACKGROUND: Treatment options for multilevel cervical spondylotic myelopathy include ACDF and cervical laminoplasty. Given that the literature has been mixed regarding the optimal approach, especially in patients without kyphosis, there is a need for additional studies investigating outcomes between ACDF and cervical laminoplasty. METHODS: A retrospective review was conducted of adult patients undergoing 3 or 4-level surgery. Patients with preoperative kyphosis based on C2-C7 Cobb angles were excluded. The electronic medical record and institutional databases were reviewed for baseline characteristics, surgical outcomes, and patient-reported outcomes. RESULTS: A total of 101 patients who underwent ACDF and 52 patients who underwent laminoplasty were included in the study. The laminoplasty cohort had a higher overall Charlson Comorbidity Index (3.10 ± 1.43 vs 2.39 ± 1.57, P = 0.011). Both groups had a comparable number of levels decompressed, C2-C7 lordosis, and diagnosis of myelopathy versus myeloradiculopathy. Patients who underwent laminoplasty had a longer length of stay (2.04 ± 1.15 vs 1.48 ± 0.70, P = 0.003) but readmission, complication, and revision rates were similar. Both groups had similar improvement in myelopathy scores (∆modified Japanese Orthopedic Association: 1.11 ± 3.09 vs 1.06 ± 3.37, P = 0.639). ACDF had greater improvement in Neck Disability Index (∆Neck Disability Index: -11.66 ± 19.2 vs -1.13 ± 11.2, P < 0.001), neck pain (∆Visual Analog Scale-neck: -2.69 ± 2.78 vs -0.83 ± 2.55, P = 0.003), and arm pain (∆Visual Analog Scale-arm: -2.47 ± 3.15 vs -0.48 ± 3.19, P = 0.010). These findings persisted in multivariate analysis except for Neck Disability Index. CONCLUSION: ACDF and cervical laminoplasty appear equally efficacious at halting myelopathic progression. However, patients who underwent ACDF had greater improvements in arm pain at 1 year postoperatively. Longitudinal studies evaluating the efficacy of laminoplasty to mitigate adjacent segment disease are indicated to establish a robust risk-benefit assessment for these 2 procedures. LEVEL OF EVIDENCE: III.

Comparison of Length of Stay and Discharge Disposition after Short-Segment Lumbar Fusion Surgery at Tertiary Care and Non-Tertiary Care Hospitals: A Propensity Score Matched Analysis.

STUDY DESIGN: A retrospective study. OBJECTIVE: To compare the perioperative and postoperative outcomes among lumbar fusion patients treated at an orthopaedic specialty hospital (OSH), a hybrid community hospital (HCH), and a conventional community hospital in comparison to a tertiary care hospital (TCH). SUMMARY OF BACKGROUND DATA: In spine surgery, strategies to reduce length of stay (LOS) include a myriad of pre-, intra-, and postoperative strategies that require a multidisciplinary infrastructure. The sum of these efforts has led to the creation of orthopedic specialty hospitals and protocols that have been adopted by community hospitals as well. There is a notable lack of information regarding the results of these efforts across different healthcare institution models. METHODS: This was a retrospective study of patients undergoing elective one or two-level lumbar fusion between 2017 and 2022 at a large urban TCH, an OSH, a HCH, and a conventional CH. Data was collected on patient characteristics, demographics, comorbidities, BMI, smoking status, surgical type, surgical levels, surgery duration, hospital length of stay, readmissions, reoperations, and discharge status within a year. Patients across the four surgical settings were matched based on age, BMI, CCI, type of procedure, and number of levels fused. RESULTS: A total of 1435 patients met the inclusion criteria. Length of hospital stay was significantly longer at TCH compared to OSH, HCH, and CH by an average of 1-2 days (P<0.001). 90-day readmissions were higher at TCH compared to OSH (P=0.001). TCH patients also were less likely to be discharged home than OSH and HCH patients (P=0.001 and P=0.016, respectively). No significant differences were noted in 1-year reoperation rates across all hospital models. CONCLUSION: Shorter lengths of stays and more home discharges at the orthopaedic specialty hospital and community hospital settings did not compromise surgical quality or postoperative outcomes.

Preoperative Electrodiagnostic Study Findings Differ Between Patients With Double-crush Syndrome and Carpal Tunnel Syndrome: A Propensity Matched Analysis.

INTRODUCTION: Double-crush syndrome (DCS) represents a condition that involves peripheral nerve compression in combination with spinal nerve root impingement. The purpose of this study was to compare electrodiagnostic study (EDS) results in patients undergoing carpal tunnel release (CTR) for carpal tunnel syndrome with those undergoing both CTR and anterior cervical diskectomy and fusion for DCS. METHODS: Patients receiving an isolated CTR were compared with those undergoing CTR and anterior cervical diskectomy and fusion within two years of CTR. The latter group was defined as our DCS cohort. Electrodiagnostic study results were collected which included sensory and motor nerve conduction data as well as electromyogram (EMG) findings. All electrodiagnostic studies were done before CTR in both sets of patients. RESULTS: Fifty-four patients with DCS and 137 CTR-only patients were included. Patients with DCS were found to have decreased sensory onset latency (3.51 vs 4.01; P = 0.015) and peak latency (4.25 vs 5.17; P = 0.004) compared with the CTR-only patients. Patients with DCS had slower wrist motor velocity (30.5 vs 47.7; P = 0.012), decreased elbow motor latency (9.62 vs 10.6; P = 0.015), and faster elbow motor velocity (56.0 vs 49.4; P = 0.031). EMG results showed that patients with DCS were more likely to have positive findings in the biceps (31.9% vs 1.96%; P < 0.001) and triceps (24.4% vs 2.97%; P < 0.001), but not abductor pollicis brevis (APB) (45.7% vs 37.9%; P = 0.459). CONCLUSION: We identified changes on EDS between patients with and without DCS. In patients with DCS, sensory nerve studies showed shorter peak and onset latency than in CTR-only patients. Interestingly, DCS and CTR-only patients had different patterns of wrist and elbow motor nerve conduction. Providers observing positive EMG findings proximal to the APB should raise their suspicion for possible cervical radiculopathy and when present with carpal tunnel syndrome-like symptoms, should also consider DCS in their diagnostic differential.

Preoperative Hounsfield Units Predict Pedicle Screw Loosening in Osteoporotic Patients Following Short Segment Lumbar Fusion.

STUDY DESIGN: Retrospective Cohort. OBJECTIVE: (1) To determine if vertebral HU values obtained from preoperative CT predict postoperative outcomes following 1-3 level lumbar fusion and (2) to investigate whether decreased BMD values determined by HU predict cage subsidence and screw loosening. SUMMARY OF BACKGROUND DATA: In light of suboptimal screening for osteoporosis, vertebral computerized tomography(CT) Hounsfield Units(HU), have been investigated as a surrogate for bone mineral density(BMD). METHODS: In this retrospective study, adult patients who underwent 1-3 level posterior lumbar decompression and fusion(PLDF) or transforaminal lumbar interbody and fusion(TLIF) for degenerative disease between the years 2017-2022 were eligible for inclusion. Demographics and surgical characteristics were collected. Outcomes assessed included 90-day readmissions, 90-day complications, revisions, patient reported outcomes(PROMs), cage subsidence, and screw loosening. Osteoporosis was defined as HU of ≤110 on preoperative CT at L1. RESULTS: We assessed 119 patients with a mean age of 59.1, of whom 80.7% were white and 64.7% were nonsmokers. The majority underwent PLDF(63%) compared to TLIF(37%), with an average of 1.63 levels fused. Osteoporosis was diagnosed in 37.8% of the cohort with a mean HU in the osteoporotic group of 88.4 compared to 169 in non-osteoporotic patients. Although older in age, osteoporotic individuals did not exhibit increased 90-day readmissions, complications, or revisions compared to non-osteoporotic patients. A significant increase in the incidence of screw loosening was noted in the osteoporotic group with no differences observed in subsidence rates. On multivariable linear regression osteoporosis was independently associated with less improvement in visual analog scale(VAS) scores for back pain. CONCLUSIONS: Osteoporosis predicts screw loosening and increased back pain. Clinicians should be advised of the importance of preoperative BMD optimization as part of their surgical planning and the utility of vertebral CT HU as a tool for risk stratification. LEVEL OF EVIDENCE: 3.

The Relationship Between Disc Herniation Morphology and Patient-Reported Outcomes after Microdiscectomy.

OBJECTIVE: Determine if herniation morphology based on the Michigan State University Classification is associated with differences in (1) patient-reported outcome measures (or (2) surgical outcomes after a microdiscectomy. METHODS: Adult patients undergoing single-level microdiscectomy between 2014 and 2021 were identified. Demographics and surgical characteristics were collected through a query search and manual chart review. The Michigan State University classification, which assesses disc herniation laterality (zone A was central, zone B/C was lateral) and degree of extrusion into the central canal (grade 1 was up to 50% of the distance to the intra-facet line, grade >1 was beyond this line), was identified on preoperative MRIs. patient-reported outcome measures were collected at preoperative, 3-month, and 1-year postoperative time points. RESULTS: Of 233 patients, 84 had zone A versus 149 zone B/C herniations while 76 had grade 1 disc extrusion and 157 had >1 grade. There was no difference in surgical outcomes between groups (P > 0.05). Patients with extrusion grade >1 were found to have lower Physical Component Score at baseline. On bivariate and multivariable logistic regression analysis, extrusion grade >1 was a significant independent predictor of greater improvement in Physical Component Score at three months (estimate = 7.957; CI: 4.443-11.471, P < 0.001), but not at 1 year. CONCLUSIONS: Although all patients were found to improve after microdiscectomy, patients with disc herniations extending further posteriorly reported lower preoperative physical function but experienced significantly greater improvement three months after surgery. However, improvement in Visual Analog Scale Leg and back, ODI, and MCS at three and twelve months was unrelated to laterality or depth of disc herniation.

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.

Significance of Facet Fluid Index in Anterior Cervical Degenerative Spondylolisthesis.

STUDY DESIGN: Retrospective cohort study. PURPOSE: To correlate cervical facet fluid characteristics to radiographic spondylolisthesis, determine if facet fluid is associated with instability in cervical degenerative spondylolisthesis, and examine whether vertebral levels with certain facet fluid characteristics and spondylolisthesis are more likely to be operated on. OVERVIEW OF LITERATURE: The relationship between facet fluid and lumbar spondylolisthesis is well-documented; however, there is a paucity of literature investigating facet fluid in degenerative cervical spondylolisthesis. METHODS: Patients diagnosed with cervical degenerative spondylolisthesis were identified from a hospital's medical records. Demographic and surgical characteristics were collected through a structured query language search and manual chart review. Radiographic measurements were made on preoperative MRIs for all vertebral levels diagnosed with spondylolisthesis and adjacent undiagnosed levels between C3 and C6. The facet fluid index was calculated by dividing the facet fluid measurement by the width of the facet. Bivariate analysis was conducted to compare facet characteristics based on radiographic spondylolisthesis and spondylolisthesis stability. RESULTS: We included 154 patients, for whom 149 levels were classified as having spondylolisthesis and 206 levels did not. The average facet fluid index was significantly higher in patients with spondylolisthesis (0.26±0.07 vs. 0.23±0.08, p <0.001). In addition, both fluid width and facet width were significantly larger in patients with spondylolisthesis (p <0.001 each). Cervical levels in the fusion construct demonstrated a greater facet fluid index and were more likely to have unstable spondylolisthesis than stable spondylolisthesis (p <0.001 each). CONCLUSIONS: Facet fluid index is associated with cervical spondylolisthesis and an increased facet size and fluid width are associated with unstable spondylolisthesis. While cervical spondylolisthesis continues to be an inconclusive finding, vertebral levels with spondylolisthesis, especially the unstable ones, were more likely to be included in the fusion procedure than those without spondylolisthesis.

How Does the Severity of Neuroforaminal Compression in Cervical Radiculopathy Affect Outcomes of Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: This study is a retrospective cohort study. PURPOSE: This study aims to determine whether preoperative neuroforaminal stenosis (FS) severity is associated with motor function patient-reported outcome measures (PROMs) following anterior cervical discectomy and fusion (ACDF). OVERVIEW OF LITERATURE: Cervical FS can significantly contribute to patient symptoms. While magnetic resonance imaging (MRI) has been used to classify FS, there has been limited research into the impact of FS severity on patient outcomes. METHODS: Patients undergoing primary, elective 1-3 level ACDF for radiculopathy at a single academic center between 2015 and 2021 were identified retrospectively. Cervical FS was evaluated using axial T2-weighted MRI images via a validated grading scale. The maximum degree of stenosis was used for multilevel disease. Motor symptoms were classified using encounters at their final preoperative and first postoperative visits, with examinations ≤3/5 indicating weakness. PROMs were obtained preoperatively and at 1-year follow-up. Bivariate analysis was used to compare outcomes based on stenosis severity, followed by multivariable analysis. RESULTS: This study included 354 patients, 157 with moderate stenosis and 197 with severe stenosis. Overall, 58 patients (16.4%) presented with upper extremity weakness ≤3/5. A similar number of patients in both groups presented with baseline motor weakness (13.5% vs. 16.55, p =0.431). Postoperatively, 97.1% and 87.0% of patients with severe and moderate FS, respectively, experienced full motor recovery (p =0.134). At 1-year, patients with severe neuroforaminal stenosis presented with significantly worse 12-item Short Form Survey Physical Component Score (PCS-12) (33.3 vs. 37.3, p =0.049) but demonstrated a greater magnitude of improvement (Δ PCS-12: 5.43 vs. 0.87, p =0.048). Worse stenosis was independently associated with greater ΔPCS-12 at 1-year (ß =5.59, p =0.022). CONCLUSIONS: Patients with severe FS presented with worse preoperative physical health. While ACDF improved outcomes and conferred similar motor recovery in all patients, those with severe FS reported much better improvement in physical function.

Lateral approach to the lumbar spine: The utility of an access surgeon.

Background: Lateral lumbar interbody fusions (LLIFs) utilize a retroperitoneal approach that avoids the intraperitoneal organs and manipulation of the anterior vasculature encountered in anterior approaches to the lumbar spine. The approach was championed by spinal surgeons; however, general/vasculature surgeons may be more comfortable with the approach. Objective: The objective of this study was to compare short-term outcomes following LLIF procedures based on whether a spine surgeon or access surgeon performed the approach. Materials and Methods: We retrospectively identified all one- to two-level LLIFs at a tertiary care center from 2011 to 2021 for degenerative spine disease. Patients were divided into groups based on whether a spine surgeon or general surgeon performed the surgical approach. The electronic medical record was reviewed for hospital readmissions and complication rates. Results: We identified 239 patients; of which 177 had approaches performed by spine surgeons and 62 by general surgeons. The spine surgeon group had fewer levels with posterior instrumentation (1.40 vs. 2.00; P < 0.001) and decompressed (0.94 vs. 1.25, P = 0.046); however, the two groups had a similar amount of two-level LLIFs (29.9% vs. 27.4%, P = 0.831). This spine surgeon approach group was found to have shorter surgeries (281 vs. 328 min, P = 0.002) and shorter hospital stays Length of Stay (LOS) (3.1 vs. 3.6 days, P = 0.019); however, these differences were largely attributed to the shorter posterior fusion construct. On regression analysis, there was no statistical difference in postoperative complication rates whether or not an access surgeon was utilized (P = 0.226). Conclusion: Similar outcomes may be seen regardless of whether a spine or access surgeon performs the approach for an LLIF.

The Impact of Unexpected Billing in Spine Surgery and How the Price Calculator Can Improve Patient Care.

STUDY DESIGN: Survey study. OBJECTIVE: The objective of this study was to determine the impact of unexpected in-network billing on the patient experience after spinal surgery. SUMMARY OF BACKGROUND DATA: The average American household faces difficulty paying unexpected medical bills. Although legislative efforts have targeted price transparency and rising costs, elective surgical costs continue to rise significantly. Patients are therefore sometimes still responsible for unexpected medical costs, the impact of which is unknown in spine surgery. METHODS: Patients who underwent elective spine surgery patients from January 2021 to January 2022 at a single institution were surveyed regarding their experience with the billing process. Demographic characteristics associated with unexpected billing situations, patient satisfaction, and financial distress, along with utilization and evaluation of the online price estimator, were collected. RESULTS: Of 818 survey participants, 183 (22.4%) received an unexpected in-network bill, and these patients were younger (56.7 vs. 63.4 y, P <0.001). Patients who received an unexpected bill were more likely to feel uninformed about billing (41.2% vs. 21.7%, P <0.001) and to report that billing impacted surgical satisfaction (53.8% vs. 19.1%, P <0.001). However, both groups reported similar satisfaction postoperatively (Likert >3/5: 86.0% vs. 85.5%, P =0.856). Only 35 (4.3%) patients knew of the price estimator's existence. The price estimator was reported to be very easy or easy (N=18, 78.2%) to understand and very accurate (N=6, 35.3%) or somewhat accurate (N=8, 47.1%) in predicting costs. CONCLUSIONS: Despite new regulations, a significant portion of patients received unexpected bills leading to financial distress and affecting their surgical experience. Although most patients were unaware of the price estimator, almost all patients who did know of it found it to be easy to use and accurate in cost prediction. Patients may benefit from targeted education efforts, including information on the price estimator to alleviate unexpected financial burden.

Utility of Seated Lateral Radiographs in the Diagnosis and Classification of Lumbar Degenerative Spondylolisthesis.

STUDY DESIGN: Retrospective cohort study. PURPOSE: Our goal was to determine which radiographic images are most essential for degenerative spondylolisthesis (DS) classification and instability detection. OVERVIEW OF LITERATURE: The heterogeneity in DS requires multiple imaging views to evaluate vertebral translation, disc space, slip angle, and instability. However, there are several restrictions on frequently used imaging perspectives such as flexion-extension and upright radiography. METHODS: We assessed baseline neutral upright, standing flexion, seated lateral radiographs, and magnetic resonance imaging (MRI) for patients identified with spondylolisthesis from January 2021 to May 2022 by a single spine surgeon. DS was classified by Meyerding and Clinical and Radiographic Degenerative Spondylolisthesis classifications. A difference of >10° or >8% between views, respectively, was used to characterize angular and translational instability. Analysis of variance and paired chi-square tests were utilized to compare modalities. RESULTS: A total of 136 patients were included. Seated lateral and standing flexion radiographs showed the greatest slip percentage (16.0% and 16.7%), while MRI revealed the lowest (12.2%, p <0.001). Standing flexion and lateral radiographs when seated produced more kyphosis (4.66° and 4.97°, respectively) than neutral upright and MRI (7.19° and 7.20°, p <0.001). Seated lateral performed similarly to standing flexion in detecting all measurement parameters and categorizing DS (all p >0.05). Translational instability was shown to be more prevalent when associated with seated lateral or standing flexion than when combined with neutral upright (31.5% vs. 20.2%, p =0.041; and 28.1% vs. 14.6%, p =0.014, respectively). There were no differences between seated lateral or standing flexion in the detection of instability (all p >0.20). CONCLUSIONS: Seated lateral radiographs are appropriate alternatives for standing flexion radiographs. Films taken when standing up straight do not offer any more information for DS detection. Rather than standing flexion-extension radiographs, instability can be detected using an MRI, which is often performed preoperatively, paired with a single seated lateral radiograph.

The impact of demineralized bone matrix characteristics on pseudarthrosis and surgical outcomes after posterolateral lumbar decompression and fusion.

Objectives: The objectives of our study were to compare the fusion rates and surgical outcomes of lumbar fusion surgery based on the (1) type of demineralized bone matrix (DBM) carrier allograft, (2) the presence/absence of a carrier, and (3) the presence of bone fibers in DBM. Methods: Patients >18 years of age who underwent single-level posterolateral decompression and fusion (PLDF) between L3 and L5 between 2014 and 2021 were retrospectively identified. We assessed bone grafts based on carrier type (no carrier, sodium hyaluronate carrier, and glycerol carrier) and the presence of bone fibers. Fusion status was determined based on a radiographic assessment of bony bridging, screw loosening, or change in segmental lordosis >5°. Analyses were performed to assess fusion rates and surgical outcomes. Results: Fifty-four patients were given DBM with a hyaluronate carrier, 75 had a glycerol carrier, and 94 patients were given DBM without a carrier. DBM carrier type, bone fibers, and carrier presence had no impact on 90-day readmission rates (P = 0.195, P = 0.099, and P = 1.000, respectively) or surgical readmissions (P = 0.562, P = 0.248, and P = 0.640, respectively). Multivariable logistic regression analysis found that type of carrier, presence of fibers (odds ratio [OR] = 1.106 [0.524-2.456], P = 0.797), and presence of a carrier (OR = 0.701 [0.370-1.327], P = 0.274) were also not significantly associated with successful fusion likelihood. Conclusion: Our study found no significant differences between DBM containing glycerol, sodium hyaluronate, or no carrier regarding fusion rates or surgical outcomes after single-level PLDF. Bone particulates versus bone fibers also had no significant differences regarding the likelihood of bony fusion.

Reasons for transfer and subsequent outcomes among patients undergoing elective spine surgery at an orthopedic specialty hospital.

Objective: To evaluate the reasons for transfer as well as the 90-day outcomes of patients who were transferred from a high-volume orthopedic specialty hospital (OSH) following elective spine surgery. Materials and Methods: All patients admitted to a single OSH for elective spine surgery from 2014 to 2021 were retrospectively identified. Ninety-day complications, readmissions, revisions, and mortality events were collected and a 3:1 propensity match was conducted. Results: Thirty-five (1.5%) of 2351 spine patients were transferred, most commonly for arrhythmia (n = 7; 20%). Thirty-three transferred patients were matched to 99 who were not transferred, and groups had similar rates of complications (18.2% vs. 10.1%; P = 0.228), readmissions (3.0% vs. 4.0%; P = 1.000), and mortality (6.1% vs. 0%; P = 0.061). Conclusion: Overall, this study demonstrates a low transfer rate following spine surgery. Risk factors should continue to be optimized in order to decrease patient risks in the postoperative period at an OSH.

The Impact of Physical Therapy After Lumbar Fusion Surgery.

STUDY DESIGN: Retrospective Cohort. OBJECTIVE: To determine if outcomes varied between patients based on physical therapy (PT) attendance after lumbar fusion surgery. SUMMARY OF BACKGROUND DATA: The literature has been mixed regarding the efficacy of postoperative PT to improve disability and back pain, as measured by patient-reported outcome measures. Given the prevalence of PT referrals and lack of high-quality evidence, there is a need for additional studies investigating the efficacy of PT after lumbar fusion surgery to aid in developing robust clinical guidelines. METHODS: We retrospectively identified patients receiving lumbar fusion surgery by current procedural terminology codes and separated them into 2 groups based on whether PT was prescribed. Electronic medical records were reviewed for patient and surgical characteristics, PT utilization, and surgical outcomes. Patient-reported outcome measures (PROMs) were identified and compared preoperatively, at 90 days postoperatively and one year postoperatively. RESULTS: The two groups had similar patient characteristics and comorbidities and demonstrated no significant differences between readmission, complication, and revision rates after surgery. Patients that attended PT had significantly more fused levels (1.41 ± 0.64 vs. 1.32 ± 0.54, P =0.027), longer operative durations (234 ± 96.4 vs. 215 ± 86.1 min, P =0.012), and longer postoperative hospital stays (3.35 ± 1.68 vs. 3.00 ± 1.49 days, P =0.004). All groups improved similarly by Oswestry Disability Index, short form-12 physical and mental health subsets, and back and leg pain by Visual Analog Scale at 90-day and 1-year follow-up. CONCLUSION: Our data suggest that physical therapy does not significantly impact PROMs after lumbar fusion surgery. Given the lack of data suggesting clear benefit of PT after lumbar fusion, surgeons should consider more strict criteria when recommending physical therapy to their patients after lumbar fusion surgery. LEVEL OF EVIDENCE: Level-Ⅲ.

The Implication of Preoperative Central Stenosis on Patient-Reported Outcomes After Lumbar Decompression Surgery.

OBJECTIVE: To assess the impact of central stenosis severity on patient-reported outcomes after lumbar decompression. METHODS: Patient diagnosis, demographics, and surgical characteristics were collected via query search and manual chart review of electronic medical records. The inclusion criteria were posterior lumbar decompressions from 2014-2020, with accessible magnetic resonance imaging reports. As previously validated by Lee et al., central stenosis was determined on magnetic resonance imaging and graded as none, mild, moderate, or severe. Patients were dichotomized into 2 groups to improve statistical power for comparisons: none or mild central stenosis and moderate or severe central stenosis. Patient-reported outcome measures (PROMs) were compared between cohorts at 1 year postoperatively. Statistical significance was set at P < 0.05. RESULTS: On bivariate analysis, no significant differences were noted between cohorts with regard to preoperative, 1-year postoperative, and delta PROMs. In addition, no significant difference in the number of patients attaining minimal clinically important difference (MCID) for each PROM was noted between cohorts. With the exception of mental score of the Short Form-12 survey, all intragroup preoperative to postoperative PROMs indicated significant improvement (all P < 0.05) after lumbar decompression surgery. Multivariate regression identified moderate or severe central canal stenosis as a significant independent predictor of improvement in visual analog scale back (estimate = -1.464, P = 0.045). CONCLUSIONS: We demonstrate that patients with moderate or severe central spinal stenosis may have more improvement in back pain than those with mild or no central stenosis after lumbar spine decompression surgery.

Perioperative Dexamethasone Does Not Reduce Postoperative Opioid Use Following Anterior Cervical Discectomy and Fusion.

OBJECTIVE: To determine if dexamethasone administration reduced narcotic consumption during hospitalization and to evaluate if patients who received dexamethasone refilled fewer opioid prescriptions postoperatively. METHODS: All adult patients who underwent primary elective 1- to 4-level anterior cervical discectomy and fusion at a single center were retrospectively identified. Prescription opioid use was collected from governmental online prescription drug monitoring programs, and in-hospital opioid use was collected from each patient's medication administration record and recorded as morphine milligram equivalents (MMEs). Patients were categorized by whether or not intravenous dexamethasone was administered perioperatively. Dexamethasone protocols were considered high dose if weight-based dosing was >0.20 mg/kg and low dose if <0.20 mg/kg. Multivariable linear regression was conducted to assess the relationship between dexamethasone administration and MMEs prescribed at each time point while accounting for confounders. RESULTS: Of 249 included patients, 167 (67%) were administered dexamethasone. Patients in both groups used a similar quantity of opioids while hospitalized (no dexamethasone: 56.7 MMEs/day vs. dexamethasone: 39.4 MMEs/day, P = 0.350). Patients in both groups refilled a similar quantity of opioids in all postoperative time periods: 0-3 weeks (3.38 vs. 4.07 MMEs/day, P = 0.528), 3-6 weeks (0.36 vs. 0.75 MMEs/day, P = 0.198), 6-12 weeks (0.53 vs. 0.75 MMEs/day, P = 0.900), and 3 months to 1 year (0.28 vs. 0.43 MMEs/day, P = 0.531). On multivariable linear regression, dexamethasone was not associated with a reduction in opioid volume at any time point (all P > 0.05). CONCLUSIONS: Administration of perioperative dexamethasone does not reduce in-hospital or home opioid usage regardless of weight-based dose. Analgesia should not be the primary driver of dexamethasone administration for anterior cervical discectomy and fusion.

Predictors of Blood Transfusion in Patients Undergoing Lumbar Spinal Fusion.

OBJECTIVE: To determine risk factors for perioperative blood transfusion after lumbar fusion surgery. METHODS: After institutional review board approval, a retrospective cohort study of adult patients who underwent lumbar fusion at a single, urban tertiary academic center was retrospectively retrieved. Our primary outcome, blood transfusion, was collected via chart query. A receiver operating characteristic curve was used to evaluate the regression model. A P-value < 0.05 was considered statistically significant. RESULTS: Of the 3,842 patients, 282 (7.3%) required a blood transfusion. For patients undergoing posterolateral decompression and fusion, predictors of transfusion included age (P < 0.001) and more levels fused (P < 0.001). A higher preoperative hemoglobin level (P < 0.001) and revision surgery (P = 0.005) were protective of blood transfusion. For patients undergoing transforaminal lumbar interbody fusion, greater Elixhauser comorbidity index (P < 0.001), longer operative time (P = 0.040), and more levels fused (P = 0.030) were independent predictors of the need for blood transfusion. Patients with a higher body mass index (P = 0.012) and preoperative hemoglobin level (P < 0.001) had a reduced likelihood of receiving a transfusion. For circumferential fusion, greater age (P = 0.006) and longer operative times (P = 0.015) were independent predictors of blood transfusion, while a higher preoperative hemoglobin level (P < 0.001) and male sex (P = 0.002) were protective. CONCLUSIONS: Our analysis identified older age, lower body mass index, greater Elixhauser comorbidity index, longer operative duration, more levels fused, and lower preoperative hemoglobin levels as independent predictors of requiring a blood transfusion following lumbar spinal fusion. Different surgical approaches were not found to be associated with transfusion.

Comparison of Postoperative Opioid Use After Anterior Cervical Diskectomy and Fusion or Posterior Cervical Fusion.

INTRODUCTION: Posterior cervical fusion (PCF) and anterior cervical diskectomy and fusion (ACDF) are two main surgical management options for the treatment of cervical spondylotic myelopathy. Although ACDF is less invasive than PCF which should theoretically reduce postoperative pain, it is still unknown whether this leads to reduced opioid use. Our objective was to evaluate whether PCF increases postoperative opioid use compared with ACDF. METHODS: We retrospectively identified all patients undergoing 2-level to 4-level ACDF or PCF at a single center from 2017 to 2021. Our state's prescription drug-monitoring program was queried for filled opioid prescriptions using milligrams morphine equivalents (MMEs) up to 1 year postoperatively. In-hospital opioid use was collected from the electronic medical record. Bivariate statistics compared ACDF and PCF cohorts. Multivariate linear regression was done to assess independent predictors of in-hospital opioid use and short-term (0 to 30 days), subacute (30 to 90 days), and long-term (3 to 12 months) opioid prescriptions. RESULTS: We included 211 ACDF patients and 91 PCF patients. Patients undergoing PCF used more opioids during admission (126.7 vs. 51.0 MME, P < 0.001) and refilled more MMEs in the short-term (118.2 vs. 86.1, P = 0.001) but not subacute (33.6 vs. 19.7, P = 0.174) or long-term (85.6 vs. 47.8, P = 0.310) period. A similar percent of patients in both groups refilled at least one prescription after 90 days (39.6% vs. 33.2%, P = 0.287). PCF (ß = 56.7, P = 0.001) and 30-day preoperative MMEs (ß = 0.28, P = 0.041) were associated with greater in-hospital opioid requirements. PCF (ß = 26.7, P = 0.039), C5 nerve root irritation (ß = 51.4, P = 0.019), and a history of depression (ß = 40.9, P < 0.001) were independently associated with 30-day postoperative MMEs. CONCLUSIONS: PCF is initially more painful than ACDF but does not lead to persistent opioid use. Surgeons should optimize multimodal analgesia protocols to reduce long-term narcotic usage rather than change the surgical approach.Level of Evidence:III.

Effect of Clinical and Radiographic Degenerative Spondylolisthesis Classification on Patient-reported Outcomes and Spinopelvic Parameters for Patients With Single-level L4-L5 Degenerative Spondylolisthesis After Lumbar Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To determine whether preoperative clinical and radiographic degenerative spondylolisthesis (CARDS) classification is associated with differences in patient-reported outcomes and spinopelvic parameters after posterior decompression and fusion for L4-L5 degenerative spondylolisthesis (DS). SUMMARY: The CARDS classification for lumbar DS, an alternative to the Meyerding system, considers additional radiographic findings such as disc space collapse and segmental kyphosis and stratifies DS into 4 radiographically distinct classes. Although CARDS has been shown to be a reliable and reproducible method for classifying DS, very few studies have assessed whether the CARDS types represent distinct clinical entities. PATIENTS AND METHODS: A retrospective cohort analysis was conducted on patients with L4-L5 DS who underwent posterior lumbar decompression and fusion. Changes in spinopelvic alignment and patient-reported outcomes measures, including recovery ratios and percentage of patients achieving the minimal clinically important difference, were compared among patients in each CARDS classification 1-year postoperatively using analysis of variance or Kruskal-Wallis H with Dunn post hoc analysis. Multiple linear regression determined whether CARDS groups significantly predicted patient-reported outcomes measures, lumbar lordosis (LL), and pelvic incidence-lumbar lordosis mismatch (PI-LL) while controlling for demographic and surgical characteristics. RESULTS: Preoperative type B spondylolisthesis predicted decreased improvement in "physical component and mental component score of the short form-12" compared with type A spondylolisthesis (ß-coefficient = -5.96, P = 0.031) at 1 year. Significant differences were found between CARDS groups with regards to ΔLL (A: -1.63 degrees vs B: -1.17 degrees vs C: 2.88 degrees vs D: 3.19 degrees, P = 0.010) and ΔPI-LL (A: 1.02 degrees vs B: 2.09 degrees vs C: -2.59 degrees vs D: -3.70 degrees, P = 0.012). Preoperative type C spondylolisthesis was found to predict increased LL (ß-coefficient = 4.46, P = 0.0054) and decreased PI-LL (ß-coefficient = -3.49, P = 0.025) at 1 year compared with type A spondylolisthesis. CONCLUSIONS: Clinical and radiographic outcomes differed significantly by preoperative CARDS classification type for patients undergoing posterior decompression and fusion for L4-L5 DS. LEVEL OF EVIDENCE: Level III.