Temporal analysis of complication rates of cervical spine surgery for degenerative spine disease between younger and older cohorts using the CSORN registry: Is age just a number?

STUDY DESIGN: An ambispective review of consecutive cervical spine surgery patients enrolled in the Canadian Spine Outcomes and Research Network (CSORN) between January 2015 and September 2019. PURPOSE: To compare complication rates of degenerative cervical spine surgery over time between older (> 65) and younger age groups (< 65). More elderly people are having spinal surgery. Few studies have examined the temporal nature of complications of cervical spine surgery by patient age groups. METHODS: Adverse events were collected prospectively using adverse event forms. Binary logistic regression analysis was utilized to assess associations between risk modifiers and adverse events at the intra-, peri-operative and 3 months post-surgery. RESULTS: Of the 761 patients studied (age < 65, n = 581 (76.3%) and 65 + n = 180 (23.7%), the intra-op adverse events were not significantly different; < 65 = 19 (3.3%) vs 65 + = 11 (6.1%), p < 0.087. Peri-operatively, the < 65 group had significantly lower percentage of adverse events (65yrs (11.2%) vs. 65 + = (26.1%), p < 0.001). There were no differences in rates of adverse events at 3 months post-surgery (< 65 = 39 (6.7%) vs. 65 + = 12 (6.7%), p < 0.983). Less blood loss (OR = 0.99, p < 0.010) and shorter length of hospital stay (OR = 0.97, p < 0.025) were associated with not having intra-op adverse events. Peri-operatively, > 1 operated level (OR = 1.77, p < 0.041), shorter length of hospital stay (OR = 0.86, p < 0.001) and being younger than 65 years (OR = 2.11, p < 0.006) were associated with not having adverse events. CONCLUSION: Following degenerative cervical spine surgery, the older and younger age groups had significantly different complication rates at peri-operative time points, and the intra-operative and 3-month post-operative complication rates were similar in the groups.

Allogeneic blood transfusions and infection risk in lumbar spine surgery: An American College of Surgeons National Surgery Quality Improvement Program Study.

BACKGROUND: Allogenic blood transfusions can lead to immunomodulation. Our purpose was to investigate whether perioperative transfusions were associated with postoperative infections and any other adverse events (AEs), after adjusting for potential confounding factors, following common elective lumbar spinal surgery procedures. STUDY DESIGN AND METHODS: We performed a multivariate, propensity-score matched, regression-adjusted retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database between 2012 and 2016. All lumbar spinal surgery procedures were identified (n = 174,891). A transfusion group (perioperative transfusion within 72 h before, during, or after principal surgery; n = 1992) and a control group (no transfusion; n = 1992) were formed. Following adjustment for between-group baseline features, adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) were calculated using a multivariate logistic regression model for any surgical site infection (SSI), superficial SSI, deep SSI, wound dehiscence, pneumonia, urinary tract infection, sepsis, any infection, mortality, and any AEs. RESULTS: Transfusion was associated with an increased risk of each specific infection, mortality, and any AEs. Statistically significant between-group differences were demonstrated with respect to any SSI (aOR: 1.48; 95% CI: 1.01-2.16), deep SSI (aOR: 1.66; 95% CI: 0.98-2.85), sepsis (aOR: 2.69; 95% CI: 1.43-5.03), wound dehiscence (aOR: 2.27; 95% CI: 0.86-6.01), any infection (aOR: 1.46; 95% CI: 1.13-1.88), any AEs (aOR: 1.80; 95% CI: 1.48-2.18), and mortality (aOR: 2.17; 95% CI: 0.77-6.36). CONCLUSION: We showed an association between transfusion and infection in lumbar spine surgery after adjustment for various applicable covariates. Sepsis had the highest association with transfusion. Our results reinforce a growing trend toward minimizing perioperative transfusions, which may lead to reduced infections following lumbar spine surgery.

Novel use of transesophageal echocardiography to optimize hemodynamics and patient positioning during prone scoliosis surgery and safety considerations in the setting of intraoperative neuromonitoring: a case report.

PURPOSE: The prone position can lead to anatomical compression of the thoracic cavity resulting in reduced cardiac output, especially in the context of chest wall deformities commonly present in patients with scoliosis. There are no protocols for using transesophageal echocardiography (TEE) to optimize prone positioning and for safe use of TEE during cases requiring neuromonitoring. CLINICAL FEATURES: We present a case of a 23-yr-old male with Cornelia de Lange syndrome undergoing elective posterior spinal fusion for syndromic scoliosis who developed severe refractory hypotension and cardiac arrest in the prone position. After hemodynamic stabilization in the intensive care unit, the patient returned to the operating room on postoperative day 2 for completion of his spinal fusion. Transesophageal echocardiography determined the optimal position of longitudinal bolster placements associated with minimal left ventricular compression in the supine position. The patient was then proned and intraoperative hemodynamics during the second surgery remained stable. Owing to the special considerations of using TEE in the prone position with neuromonitoring, we describe technical aspects to consider to protect the equipment and patient. CONCLUSION: Patients with compliant chest walls or thoracic deformities are at risk of hemodynamic instability in the prone position. Intraoperative TEE can be used in the supine patient prior to proning to determine optimal longitudinal bolster positioning to minimize cardiac compression. Transesophageal echocardiography used during spine surgery in the prone position with neuromonitoring and motor-evoked potentials requires special considerations for patient safety.

RéSUMé: OBJECTIF: La position ventrale peut entraîner une compression anatomique de la cavité thoracique provoquant une réduction du débit cardiaque, en particulier dans le contexte de déformations de la paroi thoracique, fréquentes chez les patients atteints de scoliose. Il n'existe aucun protocole guidant l'utilisation de l'échocardiographie transœsophagienne (ETO) pour optimiser le positionnement ventral et pour favoriser l'utilisation sécuritaire de l'ETO dans les cas nécessitant un neuro-monitorage. CARACTéRISTIQUES CLINIQUES: Nous présentons le cas d'un homme de 23 ans atteint d'un syndrome de Cornelia de Lange bénéficiant d'une fusion spinale postérieure non urgente pour traiter une scoliose syndromique; le patient a manifesté une hypotension réfractaire sévère et un arrêt cardiaque en position ventrale. Après stabilisation hémodynamique à l'unité de soins intensifs, le patient est retourné en salle d'opération au jour postopératoire 2 pour terminer sa fusion spinale. L'échocardiographie transœsophagienne a permis de déterminer la position optimale des traversins longitudinaux qui était associée à une compression ventriculaire gauche minimale en décubitus dorsal. Le patient a ensuite été positionné sur le ventre, et les valeurs hémodynamiques peropératoires sont restées stables au cours de la deuxième chirurgie. En raison des considérations particulières de l'utilisation de l'ETO en position ventrale avec neuro-monitorage, nous décrivons les aspects techniques à prendre en compte pour protéger l'équipement et le patient. CONCLUSION: Les patients présentant des parois thoraciques compliantes ou des déformations thoraciques sont à risque d'instabilité hémodynamique en position ventrale. L'ETO peropératoire peut être utilisée chez le patient en décubitus dorsal avant le positionnement ventral pour déterminer le positionnement optimal des traversins longitudinaux afin de minimiser la compression cardiaque. L'utilisation de l'échocardiographie transœsophagienne lors d'une chirurgie du rachis en position ventrale avec neuro-monitorage et potentiels évoqués moteurs nécessite des considérations particulières en ce qui a trait à la sécurité des patients.

Spinal pathology and outcome post-THA: does segment of arthrodesis matter?

INTRODUCTION: The presence of lumbar spine arthrodesis (SA) is associated with abnormal spinopelvic characteristics and inferior outcome post total hip arthroplasty (THA). However, whether patients with upper segment SA are also at increased risk of complications is unknown. This study aims to (1) determine if upper segment SA is associated with inferior THA outcomes; (2) assess spino-pelvic characteristics; and (3) test whether static or dynamic spinopelvic characteristics correlate with outcome post-THA. MATERIALS AND METHODS: In this retrospective, case-matched, cohort study from a tertiary referral centre, 40 patients (59 hips) that had undergone both THA and any level of spinal arthrodesis (49 THA-Lumb and 10 THA-Cerv) were compared with 41 patients (59 hips) who had THA-only without known spinal pathology. Spino-pelvic characteristics [including severity of Degenerative-Disc-Disease (DDD); spinal balance and stiffness] and outcome, including patient reported outcome measures (PROMs), at minimum of 1-year post-THA were assessed. RESULTS: THA-Lumb and THA-Cerv groups had greater number of complications and inferior hip and spinal PROMs compared to THA-Only (p < 0.001). Similar spinopelvic characteristics were seen between the THA-Cerv and THA-Lumb, which were significantly different to the THA-only group. The presence of DDD and unbalanced or stiff spine was associated with increased dislocation and inferior PROMs in the whole cohort. CONCLUSIONS: THA in the presence of SA, regardless of level, is associated with inferior outcomes and an increased risk for dislocation. The presence of a SA is associated with increased risk of adverse spinopelvic characteristics. Such characteristics were strongly associated with increased dislocation-risk and inferior PROMs. It is likely that these adverse characteristics are the most important adverse predictor, rather than segment of SA per se.

Differences in Spinopelvic Characteristics Between Hip Osteoarthritis Patients and Controls.

BACKGROUND: This study of patients with hip primary osteoarthritis and a matched, asymptomatic, volunteers (controls) group aimed to determine spinopelvic differences between the two groups and their consequences for total hip arthroplasty. METHODS: 104 patients (52 in each group) had their sagittal spinopelvic parameters (lumbar lordosis angle, sacral slope, pelvic tilt, pelvic incidence, and the pelvic-femoral angle) measured in the standing, relaxed-seated, and deep-flexed seated positions. Spinopelvic movement was calculated as the change between the different positions, and individual spinopelvic mobility was classified in accordance with the change in pelvic tilt as previously described (ΔPT: stiff (<10°), normal (10-30°), and hypermobile (>30°)). RESULTS: Transitioning from the standing to relaxed-seated position, patients demonstrated 13˚ less hip flexion (P < .001), 12˚ more posterior pelvic tilt (P = .006), and 6˚ more lumbar flexion (P = .038) compared with controls. Transitioning from the standing to deep-flexed seated position, patients demonstrated 18˚ less hip flexion (P < .001), accompanied by a posterior and not an anterior pelvic tilt as in the controls (7˚ ± 14 vs -6˚ ± 17; P < .001). Patients showed a higher percentage of spinopelvic hypermobility (19% vs 2%; P = .008). CONCLUSION: The reduced ability of flexion in the arthritic hip, leads to posterior pelvic tilt in the relaxed-seated position. This is associated with a likely compensatory increased lumbar flexion to keep an upright position. Therefore, spinopelvic hypermobility has to be defined as pathologic. When moving to the deep-flexed seated position, decreased flexion of the arthritic hip prevents the pelvis from tilting anteriorly while the lumbar spine performs a compensatory flexion by approximately the same amount compared with controls. LEVEL OF EVIDENCE: Level II, diagnostic study.

How Can Patients With Mobile Hips and Stiff Lumbar Spines Be Identified Prior to Total Hip Arthroplasty? A Prospective, Diagnostic Cohort Study.

BACKGROUND: Patients with reduced lumbar spine mobility are at higher risk of dislocation following total hip arthroplasty (THA). Therefore our study aimed to (1) define the optimal protocol for identifying patients with mobile hips and stiff lumbar spines and (2) determine clinical and standing radiographic parameters predicting these patients. METHODS: A cohort of 113 patients with end-stage hip osteoarthritis awaiting THA was prospectively studied. Clinical data, patient-reported outcome measures, and spinopelvic radiographs were assessed with the patient in the standing, "relaxed-seated," and "deep-flexed seated" position. A "hip user index" was calculated quantifying the percentage of sagittal hip movement compared to overall movement between the standing and deep-flexed seated position. RESULTS: Radiographs in the relaxed-seated position had an accuracy of 56% (95% confidence interval 46-65) to detect patients with stiff lumbar spines, compared to a detected rate of 100% in the deep-flexed seated position. A standing pelvic tilt of ≥19° was the only predictor for being a hip user with a sensitivity of 90% and specificity of 71% (area under the curve 0.83). Patients with a standing pelvic tilt ≥19° and an unbalanced spine with a flatback deformity had a 30× fold relative risk (95% confidence interval 4-226, P < .001) of being a hip user. CONCLUSION: Patients awaiting THA and having combined high hip and reduced lumbar spine mobility can be screened for with lateral standing radiographs of the spinopelvic complex. Hip user verification should be done utilizing radiographs in the deep-flexed seated position due to a higher accuracy compared to relaxed-seated radiographs. LEVEL OF EVIDENCE: Level II, diagnostic study.

Opioid use trends in patients undergoing elective thoracic and lumbar spine surgery.

Background: Opioid use in North America has increased rapidly in recent years. Preoperative opioid use is associated with several negative outcomes. Our objectives were to assess patterns of opioid use over time in Canadian patients who undergo spine surgery and to determine the effect of spine surgery on 1-year postoperative opioid use. Methods: A retrospective analysis was performed on prospectively collected data from the Canadian Spine Outcomes and Research Network for patients undergoing elective thoracic and lumbar surgery. Self-reported opioid use at baseline, before surgery and at 1 year after surgery was compared. Baseline opioid use was compared by age, sex, radiologic diagnosis and presenting complaint. All patients meeting eligibility criteria from 2008 to 2017 were included. Results: A total of 3134 patients provided baseline opioid use data. No significant change in the proportion of patients taking daily (range 32.3%-38.2%) or intermittent (range 13.7%-22.5%) opioids was found from pre-2014 to 2017. Among patients who waited more than 6 weeks for surgery, the frequency of opioid use did not differ significantly between the baseline and preoperative time points. Significantly more patients using opioids had a chief complaint of back pain or radiculopathy than neurogenic claudication (p < 0.001), and significantly more were under 65 years of age than aged 65 years or older (p < 0.001). Approximately 41% of patients on daily opioids at baseline remained so at 1 year after surgery. Conclusion: These data suggest that additional opioid reduction strategies are needed in the population of patients undergoing elective thoracic and lumbar spine surgery. Spine surgeons can be involved in identifying patients taking opioids preoperatively, emphasizing the risks of continued opioid use and referring patients to appropriate evidence-based treatment programs.

Contexte: En Amérique du Nord, l'utilisation d'opioïdes a augmenté rapidement dans les dernières années. La prise d'opioïdes en période préopératoire est associée à plusieurs issues négatives. Cette étude visait à évaluer l'évolution des tendances dans l'utilisation d'opioïdes des patients canadiens ayant subi une chirurgie spinale, et de déterminer les effets de la chirurgie sur leur utilisation 1 an après l'opération. Méthodes: Une analyse rétrospective a été réalisée à partir de données recueillies de manière prospective par le Canadian Spine Outcomes and Research Network pour les patients ayant subi une chirurgie thoracique ou une chirurgie spinale élective. On a comparé l'utilisation autodéclarée d'opioïdes au début du suivi, avant la chirurgie et 1 an après la chirurgie. L'utilisation d'opioïdes au départ a été comparée selon le sexe, l'âge, le diagnostic radiologique et le motif de consultation. Entre 2008 et 2017, tous les patients satisfaisant aux critères d'admissibilités ont été inclus dans l'étude. Résultats: Au total, 3134 patients ont fourni des données sur leur prise d'opioïdes au début du suivi. Il n'y avait pas de changement significatif dans la proportion de patients utilisant quotidiennement (32,3 % à 38,2 %) ou occasionnellement (13,7 % à 22,5 %) des opioïdes entre les patients à l'étude avant 2014 et ceux à l'étude de 2014 à 2017. Parmi les patients qui ont attendu plus de 6 semaines avant la chirurgie, la fréquence de la prise d'opioïdes n'a pas changé de manière significative entre le début du suivi et la rencontre préopératoire. Une proportion significativement plus grande de patients qui utilisaient des opioïdes consultaient principalement pour des douleurs au dos ou une radiculopathie que pour une claudication neurogène (p < 0,001), et il y avait une proportion significativement plus grande de patients de moins de 65 ans qui utilisaient des opioïdes que de patients de 65 ans ou plus (p < 0,001). Environ 41 % des patients qui prenaient quotidiennement des opioïdes au départ le faisaient aussi 1 an après la chirurgie. Conclusion: Ces données suggèrent que des stratégies supplémentaires de réduction de l'utilisation d'opioïdes sont nécessaires pour les patients qui subissent une chirurgie thoracique ou une chirurgie spinale élective. Il est possible de demander aux chirurgiens spécialisés dans ce domaine de repérer les patients qui prennent des opioïdes avant l'opération, puisque l'utilisation prolongée comporte des risques, et de les aiguiller vers un programme de traitement adéquat et fondé sur des données probantes.

Can Surgeons Adequately Capture Adverse Events Using the Spinal Adverse Events Severity System (SAVES) and OrthoSAVES?

BACKGROUND: Physicians have consistently shown poor adverse-event reporting practices in the literature and yet they have the clinical acumen to properly stratify and appraise these events. The Spine Adverse Events Severity System (SAVES) and Orthopaedic Surgical Adverse Events Severity System (OrthoSAVES) are standardized assessment tools designed to record adverse events in orthopaedic patients. These tools provide a list of prespecified adverse events for users to choose from-an aid that may improve adverse-event reporting by physicians. QUESTIONS/PURPOSES: The primary objective was to compare surgeons' adverse-event reporting with reporting by independent clinical reviewers using SAVES Version 2 (SAVES V2) and OrthoSAVES in elective orthopaedic procedures. METHOD: This was a 10-week prospective study where SAVES V2 and OrthoSAVES were used by six orthopaedic surgeons and two independent, non-MD clinical reviewers to record adverse events after all elective procedures to the point of patient discharge. Neither surgeons nor reviewers received specific training on adverse-event reporting. Surgeons were aware of the ongoing study, and reported adverse events based on their clinical interactions with the patients. Reviewers recorded adverse events by reviewing clinical notes by surgeons and other healthcare professionals (such as nurses and physiotherapists). Adverse events were graded using the severity-grading system included in SAVES V2 and OrthoSAVES. At discharge, adverse events recorded by surgeons and reviewers were recorded in our database. RESULTS: Adverse-event data for 164 patients were collected (48 patients who had spine surgery, 51 who had hip surgery, 34 who had knee surgery, and 31 who had shoulder surgery). Overall, 99 adverse events were captured by the reviewers, compared with 14 captured by the surgeons (p < 0.001). Surgeons adequately captured major adverse events, but failed to record minor events that were captured by the reviewers. A total of 93 of 99 (94%) adverse events reported by reviewers required only simple or minor treatment and had no long-term adverse effect. Three patients experienced adverse events that resulted in use of invasive or complex treatment that had a temporary adverse effect on outcome. CONCLUSION: Using SAVES V2 and OrthoSAVES, independent reviewers reported more minor adverse events compared with surgeons. The value of third-party reviewers requires further investigation in a detailed cost-benefit analysis. LEVEL OF EVIDENCE: Level II, therapeutic study.

Virtually bloodless posterior midline exposure of the lumbar spine using the "para-midline" fatty plane.

PURPOSE: The authors have developed a "para-midline" approach to the posterior lumbar spine using a virtually avascular surgical plane not previously described in the literature. It was their purpose to document consistent MRI presence of this plane and to prospectively evaluate its clinical use in terms of blood loss. METHODS: Fifty consecutive patients undergoing primary lumbar surgery on 1-3 levels were prospectively enrolled from September 2014 to May 2015. The para-midline approach was used in all cases. The deep lumbar fascia is longitudinally incised on either side of the spinous processes instead of directly in the midline, which reveals the para-midline fatty plane. Blood loss during the approach and overall blood loss were recorded for all patients. MRIs from each patient were reviewed by an experienced neuroradiologist to determine the presence of the para-midline fatty plane. RESULTS: There was no recorded blood loss during the approach for all procedures. The average overall blood loss was 60 cc (20-200 cc). No patient required a transfusion intraoperatively or postoperatively. The fatty para-midline plane was noted on preoperative MRI at all operated levels in all patients. The average width of this plane was 6.5 mm (2-17 mm). CONCLUSIONS: The para-midline approach for lumbar surgery is associated with less blood loss than traditional, subperiosteal exposure techniques. The fatty interval through which this approach is made is universally present and identifiable on MRI. The authors offer this approach as a means of decreasing the risks associated with blood loss and transfusion with posterior lumbar surgery.

A rule-based algorithm can output valid surgical strategies in the treatment of AIS.

BACKGROUND: Variability in surgical strategies for the treatment of adolescent idiopathic scoliosis (AIS) has been demonstrated despite the existence of classifications to guide selection of AIS curves to include in fusion. Decision trees and rule-based algorithms have demonstrated their potential to improve reliability of AIS classification because of their systematic approach and they have also been proposed in algorithms for selection of instrumentation levels in scoliosis. Our working hypothesis is that a rule-based algorithm with a knowledge base extracted from the literature can efficiently output surgical strategies alternatives for a given AIS case. Our objective is to develop a rule-based algorithm based on peer-reviewed literature to output alternative surgical strategies for approach and levels of fusion. METHODS: A literature search of all English Manuscripts published between 2000 and December 2009 with Pubmed and Google scholar electronic search using the following keywords: "adolescent idiopathic scoliosis" and "surgery" alternatively with "levels of fusion" or "approach". All returned abstracts were screened for contents that could contain rules to include in the knowledge base. A dataset of 1,556 AIS cases treated surgically was used to test the surgical strategy rule-based algorithm (SSRBA) and evaluate how many surgical treatments are covered by the algorithm. The SSRBA was programmed using Matlab. Descriptive statistic was used to evaluate the ability of the rule-based algorithm to cover all treatment alternatives. RESULTS: A SSRBA was successfully developed following Lenke classification's concept that the spine is divided into three curve segments [proximal thoracic (PT), main thoracic (MT) and thoracolumbar/lumbar (TL)]. Each of the 1,556 AIS patients in the dataset was ran through the SSRBA. It proposed an average of 3.78 (±2.06) surgical strategies per case. Overall, the SSRBA is able to match the treatment offered by the surgeon in approach and level of fusion 70 % of the time (with one vertebral level leeway). CONCLUSION: This study is to the author's knowledge the first attempt at proposing an algorithm to output all surgical alternatives for a given AIS case. It uses a rule-based algorithm with a knowledge base extracted from peer-reviewed literature in an area with great variability. When tested against a database of AIS patients treated surgically, the SSRBA developed has the ability to propose a surgical plan with respect to approach and levels of fusion that match the surgeon's plan in a great majority of cases. Since this SSRBA seems to output multiple valid surgical strategies, it could allow the comparisons of various strategies and the outcomes achieved in similar cases in large databases for a given case and guide surgical treatment.

Association between the ESR1 -351A>G single nucleotide polymorphism (rs9340799) and adolescent idiopathic scoliosis: a systematic review and meta-analysis.

PURPOSE: A single nucleotide polymorphism in the promoter region of the estrogen receptor alpha gene (ESR1), rs9340799, has been linked with adolescent idiopathic scoliosis (AIS) in several association studies with limited sample size and inconsistent findings. A systematic review can provide a comprehensive appraisal of literature evidence and a meta-analysis can obtain a more precise estimate of any association. The purpose of the present study was to assess and synthesize the currently available evidence on the association between rs9340799 and AIS by conducting a systematic review and meta-analysis. METHODS: This review followed the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. PubMed (MEDLINE), EMBASE, Scopus and HuGE Literature Finder databases were systematically searched to identify relevant studies following a sensitive strategy. Summary odds ratios and corresponding 95% confidence intervals (95 % CI) were estimated using the fixed-effect inverse variance model for allelic (G vs. A) and genotypic comparisons. RESULTS: Meta-analysis of four studies (n = 1,827 AIS cases and n = 1,253 controls) found a non-significant association between rs9340799 and AIS (allelic odds ratio 1.09, 95 % CI 0.96-1.23, p = 0.17). CONCLUSIONS: When examined in isolation, the rs9340799 polymorphism does not appear to be a likely susceptibility variant for AIS predisposition. However, rs9340799 may be associated with AIS severity, progression and treatment; further investigation is necessary to confirm these potential associations.

What patient parameters influence lumbar stiffness in patients with hip pathology?

Lumbar stiffness leads to greater hip dependence to achieve sagittal motion and increases instability after total hip arthroplasty (THA). We aimed to determine parameters that influence lumbar stiffness among patients with hip pathology. We hypothesized that modifiable (degenerative changes, spinal canal stenosis, facet orientation) and nonmodifiable factors (muscle condition) would be associated with lumbar spine stiffness. In this retrospective case-cohort study from a tertiary referral center, consecutive patients presenting at a hip specialist clinic underwent standing and deep-seated radiographic assessment to measure lumbar lordosis (∆LL) (stiffness: ∆LL < 20°), hip flexion (∆PFA: pelvic femoral angle), and degree of degenerative-disc-disease (DDD) (facet osteoarthritis, disc height, endplate proliferative changes). Of these, 65 patients were selected with previous lumbar spine magnetic resonance imaging, allowing to determine lumbar facet orientation, spinal canal stenosis (Schizas classification), and flexor- and extensor-muscle atrophy (Goutallier classification). Mean ∆LL was 45° (range: 11°-72°) and four patients (6%) exhibited spine stiffness. Patients with multilevel DDD (n = 22) had less ∆LL than those with no/single level (n = 43) DDD (34° [range: 11°-53°] vs. 51° [21°-72°]; p < 0.001). Number of DDD levels correlated strongly with ∆LL (ρ = -0.642; p < 0.001). Spinal stiffness was only seen in patients with ≥4 DDD levels. There was no correlation between ∆LL and facet orientation (p > 0.05). ∆LL correlated strongly with extensor atrophy at L3-L4 (ρ = -0.473), L4-L5 (ρ = -0.520), and L5-S1 (ρ = -0.473) and poorly with flexors at L4-L5 (ρ = -0.134) and L5-S1 (ρ = -0.227). Lumbar stiffness is dependent on modifiable (muscle atrophy) and nonmodifiable (extend of DDD) factors. This can guide nonoperative management of hip pathology, emphasizing the relevance of core muscle rehabilitation to improve posture and stiffness. Identification ≥4 DDD levels should alert surgeons of increased THA instability risk. Level of evidence: level IV, cohort series.

Medium Term Outcomes in Palliative Transpedicular Corpectomy with Cement Based Anterior Vertebral Reconstruction Performed for Patients with Spinal Metastasis.

STUDY DESIGN: Retrospective. OBJECTIVE: Assess the outcomes of single stage posterior transpedicular corpectomy with cement-based anterior column support for spinal metastasis at longer follow-ups. SUMMARY OF BACKGROUND DATA: Life expectancy of cancer patients is constantly increasing. Reliable anterior column reconstruction after posterior corpectomy becomes necessary. METHODS: In this retrospective monocentric study, patients who underwent posterior transpedicular corpectomy and cement-based anterior reconstruction, with a minimum 6 months follow-up, were included. Ambulatory status and pain visual analog score(PVAS), complication rates and Local Sagittal Cobb angle (LSA) were evaluated preoperatively, postoperatively and at the latest follow-up. RESULTS: In total, 253 patients were included, with a mean follow-up of 21 months [6-132] and a median survival of 9 months. Pre-operatively, 202 patients(81%) were ambulant while 47 patients (19%) weren't. At the latest follow-up, 241 patients (95%) were ambulant while 12 patients(5%) weren't (P<0.001). Dorsal/lumbar PVAS went from 8.2±2.2 pre-operatively to 5.2(±1.7) post-operatively reaching 3.4±1.9 at the latest follow-up (P<0.001). Mean LSA decreased from 13.2°(±5.78) pre-operatively to 6.11°(±8.51)(P<0.001) post-operatively and reached 7.56°(±7.55) at the latest follow-up(P=0.59). Complications occurred in 39(15.4%) patients. One-third of those were mechanical(rod/screw fracture, cement displacement) needing re-intervention in 4 patients(1.6%). CONCLUSIONS: The mechanical stability offered by the cement-based anterior reconstruction is maintained during the lifespan of patients operated for the spinal metastasis. Satisfying functional and radiological outcomes observed at the last follow-up show that this lasting, cost sparing, and relatively simple reconstruction technique, is a valid alternative for the costly and more complicated cage-based reconstruction.

Can Pelvic Incidence Change After Lumbo-Pelvic Fixation for Adult Spine Deformity, and Would the Change be Affected by the Type of Pelvic Fixation?

STUDY DESIGN: Retrospective review. OBJECTIVE: To assess the change in pelvic incidence (PI) after lumbo-pelvic fixation and the differential impact of the type of pelvic fixation: S2-alar-iliac screws (S2AI) versus Iliac screws (IS) on postoperative PI. SUMMARY OF BACKGROUND DATA: Recent studies suggest that changes occur to the previously assumed fixed PI after spino-pelvic fixation. METHODS: Adult spine deformity (ASD) patients who underwent spino-pelvic fixation with≥4 levels of fusion were included. Preoperative and postoperative PI, lumbar lordosis (LL), thoracic kyphosis, pelvic tilt, sacral slope, PI-LL mismatch, and the Sagittal Vertical Axis (SVA) were analyzed on EOS imaging. A significant PI change was established at≥6°. Patients were categorized based on the type of pelvic fixation (S2AI vs. IS). RESULTS: One-hundred-forty-nine patients were included. Of these, 77(52%) had a>6° change in their PI postoperatively. In patients with high preoperative PI (>60°), 62% had a significant PI change compared with 33% of patients with normal PI (40°-60°) and 53% in patients with low PI (<40°; P =0.01). PI was likely to decrease in patients with high baseline PI (>60°) and to increase in patients with low baseline PI (<40°). Patients with a significant PI change had a higher PI-LL. Patients in the S2AI group (n=99) and those in the IS group (n=50) were comparable at baseline. In the S2AI group, 50 (51%) patients had>6° change in their PI compared with 27(54%) patients in the IS group( P =0.65). In both groups, patients with high preoperative PI were more prone to significant postoperative changes ( P =0.02 in IS, P =0.01 in S2AI). CONCLUSION: PI changed significantly in 50% of patients postoperatively, especially in those with high/low preoperative PI and those with severe baseline sagittal imbalance. This occurs similarly in patients with S2AI and those with IS screws. Surgeons should keep in mind these anticipated changes while planning ideal LL, as this impacts postoperative PI-LL mismatch. LEVEL OF EVIDENCE: 4.

Multivariable Prediction Models for Traumatic Spinal Cord Injury: A Systematic Review.

Background: Traumatic spinal cord injuries (TSCI) greatly affect the lives of patients and their families. Prognostication may improve treatment strategies, health care resource allocation, and counseling. Multivariable clinical prediction models (CPMs) for prognosis are tools that can estimate an absolute risk or probability that an outcome will occur. Objectives: We sought to systematically review the existing literature on CPMs for TSCI and critically examine the predictor selection methods used. Methods: We searched MEDLINE, PubMed, Embase, Scopus, and IEEE for English peer-reviewed studies and relevant references that developed multivariable CPMs to prognosticate patient-centered outcomes in adults with TSCI. Using narrative synthesis, we summarized the characteristics of the included studies and their CPMs, focusing on the predictor selection process. Results: We screened 663 titles and abstracts; of these, 21 full-text studies (2009-2020) consisting of 33 distinct CPMs were included. The data analysis domain was most commonly at a high risk of bias when assessed for methodological quality. Model presentation formats were inconsistently included with published CPMs; only two studies followed established guidelines for transparent reporting of multivariable prediction models. Authors frequently cited previous literature for their initial selection of predictors, and stepwise selection was the most frequent predictor selection method during modelling. Conclusion: Prediction modelling studies for TSCI serve clinicians who counsel patients, researchers aiming to risk-stratify participants for clinical trials, and patients coping with their injury. Poor methodological rigor in data analysis, inconsistent transparent reporting, and a lack of model presentation formats are vital areas for improvement in TSCI CPM research.

Preoperative expectations of patients with degenerative cervical myelopathy: an observational study from the Canadian Spine Outcomes and Research Network.

BACKGROUND: Despite an abundance of literature on degenerative cervical myelopathy (DCM), little is known about preoperative expectations of these patients. PURPOSE: The primary objective was to describe patient preoperative expectations. Secondary objectives included identifying patient characteristics associated with high preoperative expectations and to determine if expectations varied depending on myelopathy severity. STUDY DESIGN: This was a retrospective study of a prospective multicenter, observational cohort of patients with DCM. PATIENT SAMPLE: Patients who consented to undergo surgical treatment between January 2019 and September 2022 were included. OUTCOMES MEASURES: An 11-domain expectation questionnaire was completed preoperatively whereby patients quantified the expected change in each domain. METHODS: The most important expected change was captured. A standardized expectation score was calculated as the sum of each expectation divided by the maximal possible score. The high expectation group was defined by patients who had an expectation score above the 75th percentile. Predictors of patients with high expectations were determined using multivariable logistic regression models. RESULTS: There were 262 patients included. The most important patient expectation was preventing neurological worsening (40.8%) followed by improving balance when standing or walking (14.5%), improving independence in everyday activities (10.3%), and relieving arm tingling, burning and numbness (10%). Patients with mild myelopathy were more likely to select no worsening as the most important expected change compared to patients with severe myelopathy (p<.01). Predictors of high patient expectations were: having fewer comorbidities (OR -0.30 for every added comorbidity, 95% CI -0.59 to -0.10, p=.01), a shorter duration of symptoms (OR 0.92, 95% CI 0.35-1.19, p=.02), no contribution from "failure of other treatments" on the decision to undergo surgery (OR 1.49, 95% CI 0.56-2.71, p=.02) and more severe neck pain (OR 0.19 for 1 point increase, 95% CI 0.05-0.37, p=.01). CONCLUSIONS: Most patients undergoing surgery for DCM expect prevention of neurological decline, better functional status, and improvement in their myelopathic symptoms. Stopping neurological deterioration is the most important expected outcomes by patients.

Factors associated with increased length of stay in degenerative cervical spine surgery: a cohort analysis from the Canadian Spine Outcomes and Research Network.

OBJECTIVE: Postoperative length of stay (LOS) significantly contributes to healthcare costs and resource utilization. The primary goal of this study was to identify patient, clinical, surgical, and institutional variables that influence LOS after elective surgery for degenerative conditions of the cervical spine. The secondary objectives were to examine the variability in LOS and institutional practices used to decrease LOS. METHODS: This was a multicenter observational retrospective cohort study of patients enrolled in the Canadian Spine Outcomes and Research Network (CSORN) between January 2015 and October 2020 who underwent elective anterior cervical discectomy and fusion (ACDF) (1-3 levels) or posterior cervical fusion (PCF) (between C2 and T2) with/without decompression for degenerative conditions of the cervical spine. Prolonged LOS was defined as LOS greater than the median for the ACDF and PCF populations. The principal investigators at each participating CSORN healthcare institution completed a survey to capture institutional practices implemented to reduce postoperative LOS. RESULTS: In total, 1228 patients were included (729 ACDF and 499 PCF patients). The median (IQR) LOS for ACDF and PCF were 1.0 (1.0) day and 5.0 (4.0) days, respectively. Predictors of prolonged LOS after ACDF were female sex, myelopathy diagnosis, lower baseline SF-12 mental component summary score, multilevel ACDF, and perioperative adverse events (AEs) (p < 0.05). Predictors of prolonged LOS after PCF were nonsmoking status, education less than high school, lower baseline numeric rating scale score for neck pain and EQ5D score, higher baseline Neck Disability Index score, and perioperative AEs (p < 0.05). Myelopathy did not significantly predict prolonged LOS within the PCF cohort after multivariate analysis. Of the 8 institutions (57.1%) with an enhanced recovery after surgery (ERAS) protocol or standardized protocol, only 3 reported using an ERAS protocol specific to patients undergoing ACDF or PCF. CONCLUSIONS: Patient and clinical factors predictive of prolonged LOS after ACDF and PCF are highly variable, warranting individual consideration for possible mitigation. Perioperative AEs remained a consistent independent predictor of prolonged LOS in both cohorts, highlighting the importance of preventing intra- and postoperative complications.

The Effects of Peri-Operative Adverse Events on Clinical and Patient-Reported Outcomes After Surgery for Degenerative Cervical Myelopathy: An Observational Cohort Study from the Canadian Spine Outcomes and Research Network.

BACKGROUND AND OBJECTIVES: There is a lack of data examining the effects of perioperative adverse events (AEs) on long-term outcomes for patients undergoing surgery for degenerative cervical myelopathy. We aimed to investigate associations between the occurrence of perioperative AEs and coprimary outcomes: (1) modified Japanese Orthopaedic Association (mJOA) score and (2) Neck Disability Index (NDI) score. METHODS: We analyzed data from 800 patients prospectively enrolled in the Canadian Spine Outcomes and Research Network multicenter observational study. The Spine AEs Severity system was used to collect intraoperative and postoperative AEs. Patients were assessed at up to 2 years after surgery using the NDI and the mJOA scale. We used a linear mixed-effect regression to assess the influence of AEs on longitudinal outcome measures as well as multivariable logistic regression to assess factors associated with meeting minimal clinically important difference (MCID) thresholds at 1 year. RESULTS: There were 167 (20.9%) patients with minor AEs and 36 (4.5%) patients with major AEs. The occurrence of major AEs was associated with an average increase in NDI of 6.8 points (95% CI: 1.1-12.4, P = .019) and reduction of 1.5 points for mJOA scores (95% CI: -2.3 to -0.8, P < .001) up to 2 years after surgery. Occurrence of major AEs reduced the odds of patients achieving MCID targets at 1 year after surgery for mJOA (odds ratio 0.23, 95% CI: 0.086-0.53, P = .001) and for NDI (odds ratio 0.34, 95% CI: 0.11-0.84, P = .032). CONCLUSION: Major AEs were associated with reduced functional gains and worse recovery trajectories for patients undergoing surgery for degenerative cervical myelopathy. Occurrence of major AEs reduced the probability of achieving mJOA and NDI MCID thresholds at 1 year. Both minor and major AEs significantly increased health resource utilization by reducing the proportion of discharges home and increasing length of stay.