Academic and Demographic Characteristics of Pediatric Orthopaedic Division Chiefs in the United States.

INTRODUCTION: Division Chiefs (DCs) and department leadership play an integral role within the service. The goal of this study is to assess the demographics and scholarly work of the leadership in pediatric orthopaedics services across the United States and comment on the role of diversity within leadership positions. METHODS: Academic medical centers and pediatric hospitals were identified using the Electronic Residency Application Service website, the Pediatric Orthopaedic Society of North America website, and the Children's Hospital Association website. Leadership was identified using the hospitals' respective websites where data such as sex, race/ethnicity, fellowship institution, time since graduating fellowship, and academic rank were collected. Scopus database was used to determine h-indices and PubMed was used to determine the number of publications. RESULTS: Of 196 academic centers and 223 pediatric hospitals identified, 98 had a designated DC of the pediatric orthopaedics division. The majority of the DCs were male (85.7%), and leadership positions at hospitals with academic affiliations had a higher proportion of female DCs than nonacademic centers ( P =0.0317). DCs were mostly white (83.7%), followed by Asian (12.2%), and African American (2.0%). The average time since fellowship was 21.1 years and the average h-index was 15.7. The average age of the DCs was 56.8 years old. Of those in academic settings, 48.5% held the rank of professor. The fellowship programs that trained the most DCs were Boston Children's Hospital (16.3%) and Texas Scottish Rite for Children (14.3%). DISCUSSION: There is a paucity of available research on leadership characteristics in pediatric orthopaedic surgery. While progress has been made, there is still a lack of diversity that exists among leadership in pediatric orthopaedics, both within the academic setting as well as the private sector. The position of DC is held predominately by white males with a rank of either professor or no academic association. Intentional efforts are needed to continue to increase diversity in leadership positions within pediatric orthopaedic programs in the United States. LEVEL OF EVIDENCE: IV.

Biologics in Spine Fusion.

Achieving fusion in spine surgery can be challenging because of patient factors such as smoking and diabetes. The consequences of pseudarthrosis can be severe, including pain, instability, and additional surgery. Autologous iliac crest bone graft is the historical standard for augmenting spine fusion, providing high rates of fusion throughout the cervical, thoracic, and lumbar spine. Harvest of autologous iliac crest bone can be associated with comorbidities and this has led to development of alternative biologic materials to enhance spine fusion. Substitutes include various forms of allograft products including decellularized allograft; demineralized bone matrix; synthetic materials including bioactive glass; and autologous and allograft mesenchymal stem cells. Bone morphogenetic proteins can be efficacious for fusion but have significant risks and are not suitable for all spine procedures. There is a wide variety of utilization of biologics for spine fusion that are influenced by spinal region, surgeon preference, surgical training, health system formulary, and cost.

Determining the Generalizability of the PROMIS Depression Domain's Floor Effect and Completion Time in Patients Undergoing Orthopaedic Surgery.

BACKGROUND: Depression is common and can decrease the likelihood that a patient undergoing an orthopaedic procedure will improve after that intervention. Research at a single institution using the Patient-reported Outcomes Measurement Information System (PROMIS) showed that the PROMIS Depression domain had a substantial floor effect (lowest depressive symptoms measurable) in patients with orthopaedic conditions, although the instrument is designed to follow a population-based normal distribution. Patients with the lowest scores (floor) completed the questionnaire more quickly than those who did not have the lowest scores, which suggests that patients may not want to report or discuss depressive symptoms with their orthopaedic surgeon. QUESTIONS/PURPOSES: (1) Do the scores of a large population of patients with orthopaedic conditions completing the PROMIS Physical Function (PF), Pain Interference (PI), and Depression questionnaires follow the normal population distribution used to calibrate the PROMIS instrument? (2) Do the scores of a large population of patients with foot and ankle, spine, upper extremity, multiple orthopaedic subspecialty, or other orthopaedic conditions completing the PROMIS Depression questionnaire follow the normal population distribution used to calibrate the PROMIS instrument? (3) Do all orthopaedic patients with the lowest possible score (floor effect) on the PROMIS Depression questionnaire answer questions more quickly than those who do not? METHODS: Between February 12, 2015 and July 19, 2018, a total of 513,042 patients with orthopaedic conditions at a single urban, tertiary academic medical center were asked to complete the PROMIS PF, PI, and Depression domains. The PROMIS PF, PI, and Depression questionnaires were administered at 433,939 patient encounters (85%), and 325,251 of 433,939 (75%) completed all three questionnaires and were included in our final sample. The remaining encounters were excluded from all analyses because of incomplete PROMIS data. Using this large sample size, we determined the distributions of the PROMIS PF, PI, and Depression domains for all patients with orthopaedic conditions by visual inspection. We calculated the percentage of patients with the lowest possible score on the PROMIS Depression domain ("floor group") for all patients with orthopaedic conditions, as well for patients presenting to orthopaedic subspecialists (foot and ankle, spine, upper extremity, multiple subspecialties, or other specialists). We compared patient and PROMIS characteristics between patients in the floor group and all others ("standard group") using a bivariate analysis, including the total time it took to complete the questionnaires and average time it took to answer each question. RESULTS: Of the three PROMIS domains analyzed, only the PROMIS PF demonstrated a normal distribution on visual inspection. PROMIS PI scores had a measurable ceiling effect (more pain symptoms) (15,520 of 325,251 patient encounters; 5%), while PROMIS Depression scores demonstrated a clear floor effect (65,226 of 325,251; 20%). When analyzed by subspecialty, there was a clear floor effect for the PROMIS Depression in the specialties of foot and ankle (6031 of 29,273 patient encounters; 21%), spine (7611 of 58,266; 13%), upper extremity (9851 of 42,864; 23%), multiple subspecialties (276 of 1662; 17%), and other (41, 454 of 193,185; 22%). Generally, those in the floor group spent less time per question on the PROMIS Depression questionnaire than did those in the standard group (5.3 seconds ± 2.6 seconds versus 8.1 seconds ± 4.6 seconds; mean difference, 2.8 seconds; p < 0.001). CONCLUSIONS: The substantial floor effect of the PROMIS Depression in the setting of hasty completion raises the question of whether such results truly indicate that these patients have minimal depression or whether they simply do not report their true mental health status in an orthopaedic setting. When such patients are seen in clinic, surgeons may benefit from using the PROMIS Depression as an educational opportunity to explain the importance of mental health in orthopaedic care and ensure the questionnaire is completed accurately. This study builds on previous work by suggesting these findings apply to other general and subspecialty orthopaedic patient populations at academic medical centers. Future work may seek to determine the best way of ensuring that the PROMIS Depression questionnaire is completed accurately in orthopaedic clinics. LEVEL OF EVIDENCE: Level II, diagnostic study.

Interest in Orthopedic Surgery Residency: A Google Trends Analysis.

Google Trends, a powerful online search tool, was used to evaluate the association between the United States applicant pool for orthopedic surgery residency and Internet queries for orthopedic residency and orthopedic salary. From 2006 to 2015, searches for orthopedic salary and orthopedic residency were conducted by Google Trends. Data from the National Residency Match Program (NRMP) in the same time period was plotted and subsequently compared to the Google Trends results. From 2006 to 2015, Google Trends demonstrated an increase in orthopedic residency queries with the largest increase between 2008 and 2010. Orthopedic salary searches increased over the study period, with the sharpest increase from 2008 to 2009. NRMP demonstrated an increase over the study period in U.S. medical school orthopedic surgery applicants and positions filled. The Google Trends analysis mirrored the data from the NRMP, suggesting that online search tools could be of important predictive value for medical students' interest in orthopedic surgery residency. (Journal of Surgical Orthopaedic Advances 27(2):98-101, 2018).

What Factors Influence Compliance With Sequential Compression Devices in an Orthopaedic Unit: A Quality Assurance Observational Study.

The purpose of this study was to determine the compliance rate with sequential suppression devices (SCDs) of patients admitted to an orthopaedic unit of a level I trauma center. A quality assurance observational study was conducted over a 4-week period (June/July 2015). Three observations were performed per 24-hour period (0700, 1300, 1900 hours). ``Full SCD compliance'' was defined as the SCD ordered, on and functioning properly at the time of observation. Of the 1356 observations in 109 patients, 434 (32%) were fully compliant with SCD prophylaxis. SCD compliance in trauma patients was higher (21%) as compared with elective surgical patients (10%) (p < .0001). Morning observations had the highest compliance rate (38.3%), whereas the afternoon (23.5%) and evening observations (33.1%) had less compliance rates (p < .0001). There was a significantly higher compliance rate on weekdays (33.9%) as compared with weekends (28%) (p < .03). The overall low compliance level (32%) indicates compliance challenges and not the modality of the prophylaxis as the cause (Journal of Surgical Orthopaedic Advances 27(4):307-311, 2018).

Management of metastatic cervical spine tumors.

The skeletal system is the third most common site of metastases after the lung and liver. Within the skeletal system, the vertebral column is the most common site of metastases, and 8% to 15% of vertebral metastases are in the cervical spine, consisting, anatomically and biomechanically, of the occipitocervical junction, subaxial spine, and cervicothoracic junction. The vertebral body is more commonly affected than the posterior elements. Nonsurgical management techniques include radiation therapy (stereotactic and conventional), bracing, and chemotherapy. Surgical techniques include percutaneous methods, such as vertebroplasty, and palliative methods, such as decompression and stabilization. Surgical approach depends on the location of the tumor and the goals of the surgery. Appropriate patient selection can lead to successful surgical outcomes by restoring spinal stability and improving quality of life.

Mycobacterium kansasii infection of the spine in a patient with sarcoidosis: a case report and literature review.

Mycobacterium kansasii is an acid-fast bacillus most commonly associated with pulmonary pathology. Infection of the spine is exceedingly rare, with just three reported cases, two of which were in human immunodeficiency virus and acquired immunodeficiency syndrome patients. This case report presents a case of vertebral osteomyelitis secondary to M. kansasii infection and reviews existing literature on this pathogen. The patient, a 37-year-old male with sarcoidosis, sustained a M. kansasii infection of the spine, resulting in vertebral osteomyelitis of L1 and L2 and discitis of the L1-L2 disc. This finding was confirmed by bone and intervertebral disc biopsy. Initially, the patient was thought to have a compression fracture of L2. However, the decision to perform a biopsy was made because of the patient's persistent febrile episodes and magnetic resonance imaging findings. The patient did not have any neurological deficits. He was successfully treated with antimicrobials, with no recurrent symptoms at 2-year follow-up. This case is the first reported case of a M. kansasii infection of the spine in a patient with sarcoidosis.

Patient-Reported Outcomes for Spine Oncology: A Narrative Review.

Spine tumors, both primary and metastatic, impose significant morbidity and mortality on patients and physicians. Patient-reported outcomes are valuable tools to assess a patient's impression of their health status and enhance communication between physicians and patients. Various spine generic patient-reported outcome tools have traditionally been used but have not been validated in the spine tumor patient population. The Spine Oncology Study Group Outcome Questionnaire, which is disease-specific for the metastatic spine patient population, has been shown to have strong validity, even across multiple languages. Patient-Reported Outcomes Measurement Information System, which has recently been developed, employs computerized adaptive testing to assess multiple health domains. It has been shown to capture information in both generic and specific questionnaires and has the potential to be used as a universal tool in the spine oncology patient population. Further long-term studies, as well as, cross-cultural adaptations, are needed to validate Patient-Reported Outcomes Measurement Information System's applicability and effectiveness.

The top-cited military relevant spine articles.

Introduction: Historically musculoskeletal injury has substantially affected United States (US) service members. Lumbosacral spine injuries are among the most common sites of injury for service members across all US military branches and usually presents with pain in the lower back and extremities. The aim of this study is to identify and describe the 50 most-cited articles relevant to military medicine on the subject of the spine. Methods: In April 2020 Web of Science was used to search the key words: spinal cord injury, spine, thoracic spine, lumbar spine, cervical spine, sacrum, sacral, cervical fusion, lumbar fusion, sacral fracture, combat, back pain, neck pain, and military. Articles published from 1900 to 2020 were evaluated for relevance to military spine orthopaedics and ranked based on citation number. The 50 most-cited articles were characterized based on country of origin, journal of publication, affiliated institution, topic, military branch, and conflict. Results: 1900 articles met search criteria. The 50 most-cited articles were cited 24 to 119 times and published between 1993 and 2017. 30 articles (60%) originated in the United States. Aviation, Space, and Environmental Medicine accounted for the most frequent (n = 10) destination journal followed by Spine (n = 8). 37 institutions contributed to the top 50 most-cited articles. The most common article type was clinically focused retrospective analysis 36% (n = 18), clinically focused cohort study 10% (n = 5), and clinically focused cohort questionnaire, cross-sectional analysis, and randomized study 8% each (n = 4). 90% of articles were non-surgical (n = 45). The US Army had the greatest number of associated articles. Operation Iraqi Freedom and Operation Enduring Freedom were the most-cited conflicts. Conclusion: The 50 most-cited articles relevant to military spine orthopaedics are predominantly clinically focused, arising from the US, and published in Aviation, Space, and Environmental Medicine, Spine, and The Spine Journal.

Prevalence, Characteristics, and Trends in Retracted Spine Literature: 2000-2023.

BACKGROUND: Retraction of scientific publications is an important check on scientific misconduct and serves to maintain the integrity of the scientific literature. The present study aims to examine the prevalence, trends, and characteristics of retracted spine literature across basic science and clinical spine literature. METHODS: Multiple databases were queried for retracted papers relating to spine or spine surgery, between January 2000 and May 2023. Of 112,668 publications initially identified, 125 were ultimately included in the present study following screening by 2 independent reviewers. Journal of origin, reasons for retraction, date of publication, date of retraction, impact factor of journal, countries of research origin, and study design were collected for each included publication. RESULTS: Clinical studies were the most frequent type of retracted publication (n = 70). The most common reason for retraction was fraud (n = 58), followed by plagiarism (n = 22), and peer review process manipulation (n = 16). Impact factors ranged from 0.3 to 11.1 with a median of 3.75. Average months from publication to retraction across all studies was 37.5 months. The higher the journal impact factor, the longer the amount of time between publication and retraction (P = 0.01). China (n = 63) was the country of origin of more than half of all retracted spine publications. CONCLUSIONS: The rate of retractions has been increasing over the past 23 years, and clinical studies have been the most frequently retracted publication type. Clinicians treating disorders of the spine should be aware of these trends when relying on the clinical literature to inform their practice.

Relationship between 25-hydroxy Vitamin D level and surgical site infection in spine surgery.

Background: 25-hydroxy Vitamin D (25[OH]D) level has been shown to have antimicrobial and wound healing effects in animal models. Low preoperative 25(OH)D has been shown to correlate with surgical site infection (SSI) in thoracolumbar spine surgery. Methods: This study involved 545 patients undergoing thoracolumbar spine surgery from 2012 to 2019 at an academic medical center. We evaluated the serum 25(OH)D level (i.e., adequate level = level 30-60 ng/dL), along with SSI, body mass index, and smoking status. Statistical analysis was done using bivariate analysis with Fisher's exact, Wilcoxon rank-sum test and multivarible logisitic regression analyses. Results: We included 545 patients in the study, and there were no statistical differences in the average preoperative 25(OH)D between SSI and non-SSI groups. The average 25(OH)D in the non-SSI group was 31.6 ng/dL ± 13.6, and the SSI group was 35.7 ng/dL ± 20.2 (P = 0.63). Conclusion: SSI rates following thoracolumbar spine surgery were not affected by preoperative 25(OH)D levels.

AOA Critical Issues Symposium: Advancing Diversity, Equity, and Inclusion in Orthopaedic Surgery.

ABSTRACT: In recent years, the medical field has recognized the pivotal role of diversity, equity, and inclusion (DEI) in enhancing patient care and addressing health-care disparities. Orthopaedic surgery has embraced these principles to create a more inclusive and representative workforce. A DEI symposium that was sponsored by the American Orthopaedic Association convened orthopaedic surgeons, researchers, educators, and stakeholders to discuss challenges and strategies for implementing DEI initiatives. The symposium emphasized the importance of equity, and fostered conversations on creating equal opportunities and resources. Speakers covered key topics, including establishing DEI divisions, metrics for success, DEI leadership, and available resources, and promoted excellence and innovation in orthopaedic surgery through a more diverse and inclusive approach.

The Rowing Spine: A Review of Biomechanics, Injury, and Treatment.

OBJECTIVE: We aimed to describe spinal biomechanics and injury patterns in rowing. METHODS: In this systematic literature review, a Google and PubMed literature search was undertaken using keywords "rowing," "biomechanics," and "spine." RESULTS: Relevant articles were reviewed and synthesized to describe biomechanics, injury patterns, treatment options, and techniques for injury prevention. CONCLUSIONS: Rowing has increased in popularity throughout the United States. Up-to-date knowledge of rowing biomechanics and spinal injury patterns is necessary for prompt diagnosis and appropriate treatment of the injured rowing athlete.

Addressing the Impact of Race and Ethnicity on Musculoskeletal Spine Care in the United States.

➤ Despite being a social construct, race has an impact on outcomes in musculoskeletal spine care.➤ Race is associated with other social determinants of health that may predispose patients to worse outcomes.➤ The musculoskeletal spine literature is limited in its understanding of the causes of race-related outcome trends.➤ Efforts to mitigate race-related disparities in spine care require individual, institutional, and national initiatives.

Clinical Improvement After Lumbar Fusion: Using PROMIS to Assess Recovery Kinetics.

STUDY DESIGN: Retrospective review of a single institution cohort. OBJECTIVE: The goal of this study is to identify features that predict delayed achievement of minimum clinically important difference (MCID) following elective lumbar spine fusion using Patient-Reported Outcomes Measurement Information System (PROMIS) surveys. SUMMARY OF BACKGROUND DATA: Preoperative prediction of delayed recovery following lumbar spine fusion surgery is challenging. While many studies have examined factors impacting the achievement of MCID for patient-reported outcomes in similar cohorts, few studies have assessed predictors of early functional improvement. METHODS: We retrospectively reviewed patients undergoing elective one-level posterior lumbar fusion for degenerative pathology. Patients were subdivided into two groups based on achievement of MCID for each respective PROMIS domain either before six months ("early responders") or after six months ("late responders") following surgical intervention. Multivariable logistic regression analysis was used to determine features associated with odds of achieving distribution-based MCID before or after six months follow up. RESULTS: 147 patients were included. The average age was 64.3±13.0 years. At final follow-up, 57.1% of patients attained MCID for PI and 72.8% for PF. However, 42 patients (49.4%) reached MCID for PI by six months, compared to 44 patients (41.1%) for PF. Patients with severe symptoms had the highest probability of attaining MCID for PI (OR 10.3; P =0.001) and PF (OR 10.4; P =0.001) Preoperative PROMIS symptomology did not predict early achievement of MCID for PI or PF. Patients who received concomitant iliac crest autograft during their lumbar fusion had increased odds of achieving MCID for PI (OR 8.56; P =0.001) before six months. CONCLUSION: Our study demonstrated that the majority of patients achieved MCID following elective one-level lumbar spine fusion at long-term follow-up, although less than half achieved this clinical benchmark for each PROMIS metric by six months. We also found that preoperative impairment was not associated with when patients would achieve MCID. Further prospective investigations are warranted to characterize the trajectory of clinical improvement and identify the risk factors associated with poor outcomes more accurately.

Socioeconomic disadvantage is correlated with worse PROMIS outcomes following lumbar fusion.

BACKGROUND CONTEXT: Socioeconomic status (SES) has been associated with differential healthcare outcomes and may be proxied using the area-deprivation index (ADI). Few studies to date have investigated the role of ADI on patient-reported outcomes and clinically meaningful improvement following lumbar spine fusion surgery. PURPOSE: The purpose of this study is to investigate the role of SES on lumbar fusion outcomes using Patient-Reported Outcomes Measurement Information System (PROMIS) surveys. STUDY DESIGN/SETTING: Retrospective review of a single institution cohort. PATIENT SAMPLE: About 205 patients who underwent elective one-to-three level posterior lumbar spine fusion. OUTCOME MEASURES: Change in PROMIS scores and achievement of minimum clinically important difference (MCID). METHODS: Patients 18 years or older undergoing elective one-to-three level lumbar spine fusion secondary to spinal degeneration from January 2015 to September 2021 with minimum one year follow-up were reviewed. ADI was calculated using patient-supplied addresses and patients were grouped into quartiles. Higher ADI values represent worse deprivation. Minimum clinically important difference (MCID) thresholds were calculated using distribution-based methods. Analysis of variance testing was used to assess differences within and between the quartile cohorts. Multivariable regression was used to identify features associated with the achievement of MCID. RESULTS: About 205 patients met inclusion and exclusion criteria. The average age of our cohort was 66±12 years. The average time to final follow-up was 23±8 months (range 12-36 months). No differences were observed between preoperative baseline scores amongst the four quartiles. All ADI cohorts showed significant improvement for pain interference (PI) at final follow-up (p<.05), with patients who had the lowest socioeconomic status having the lowest absolute improvement from preoperative baseline physical function (PF) and PI (p=.01). Only those patients who were in the lowest socioeconomic quartile failed to significantly improve for PF at final follow-up (p=.19). There was a significant negative correlation between socioeconomic level and the absolute proportion of patients reaching MCID for PI (p=.04) and PF (p=.03). However, while ADI was a significant predictor of achieving MCID for PI (p=.02), it was nonsignificant for achieving MCID for PF. CONCLUSIONS: Our study investigated the influence of ADI on postoperative PROMIS scores and identified a negative correlation between ADI quartile and the proportion of patients reaching MCID. Patients in the worse ADI quartile had lower chances of reaching clinically meaningful improvement in PI. Policies focused on alleviating geographical deprivation may augment clinical outcomes following lumbar surgery.

Exploring the Impact of TLR-2 Signaling on miRNA Dysregulation in Intervertebral Disc Degeneration.

Toll-like receptors (TLRs) are key mediators of inflammation in intervertebral disc (IVD) degeneration. TLR-2 activation contributes to the degenerative process by increasing the expression of extracellular matrix-degrading enzymes, pro-inflammatory cytokines, and neurotrophins. As potent post-transcriptional regulators, microRNAs can modulate intracellular mechanisms, and their dysregulation is known to contribute to numerous pathologies. This study aims to investigate the impact of TLR-2 signaling on miRNA dysregulation in the context of IVD degeneration. Small-RNA sequencing of degenerated IVD cells shows the dysregulation of ten miRNAs following TLR-2 activation by PAM2CSK4. The miR-155-5p is most significantly upregulated in degenerated and non-degenerated annulus fibrosus and nucleus pulposus cells. Sequence-based target and pathway prediction shows the involvement of miR-155-5p in inflammation- and cell fate-related pathways and TLR-2-induced miR-155-5p expression leads to the downregulation of its target c-FOS. Furthermore, changes specific to the activation of TLR-2 through fragmented fibronectin are seen in miR-484 and miR-487. Lastly, miR-100-3p, miR-320b, and miR-181a-3p expression exhibit degeneration-dependent changes. These results show that TLR-2 signaling leads to the dysregulation of miRNAs in IVD cells as well as their possible downstream effects on inflammation and degeneration. The identified miRNAs provide important opportunities as potential therapeutic targets for IVD degeneration and low back pain.

Sickle Cell Disease Has No Impact on 10-Year Cumulative Incidence and Indications for Revision Lumbar Fusion.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVES: Patients with sickle cell disease (SCD) experience distinct physiological challenges that may alter surgical outcomes. There has been no research establishing 10-year lumbar fusion (LF) implant survivorship rates among individuals with SCD. This study aims to determine the 10-year cumulative incidence and indications for revision LF between patients with and without SCD. METHODS: A national database was queried to identify patients with and without SCD who underwent primary LF. SCD patients undergoing LF were propensity-score matched in a 1:4 ratio by age, gender, and Charlson Comorbidity Index (CCI) to a matched LF control. In total, 246 SCD patients were included along with 981 and 100,000 individuals in the matched and unmatched control cohorts, respectively. Kaplan-Meier survival analysis was utilized to determine the 10-year cumulative incidence rates of revision LF. Furthermore, multivariable analysis using Cox proportional hazard modeling was performed to compare indications for revisions and surgical complications between cohorts including hardware removal, drainage and evacuation, pseudoarthrosis, and mechanical failure. RESULTS: No significant differences were found in the cumulative incidence of 10-year all-cause revision LF between patients in the SCD cohort and either of the control cohorts (P > .05 for each). Additionally, there were no significant differences between the SCD cohort and either of the control cohorts in regards to the indications for revision or surgical complications in LF (P > .05 for each). CONCLUSIONS: This study indicates that SCD patients do not have increased risk for revision LF, nor any of its indications.

Higher 2-Year Cumulative Incidence of Mental Health Disorders Following Irrigation and Debridement in Primary Lumbar Fusion.

Introduction: Spinal fusion is an operation that is employed to treat spinal diseases. Surgical site infection (SSI) after lumbar fusion (LF) is a postoperative complication. SSI is treated with irrigation and debridement (I&D), which requires readmittance following discharge or prolonged hospital stays, which are deleterious to patients' mental health. The long-term relationship between treating SSI with I&D and patients' mental health is still understudied. Methods: Using the Mariner dataset from the PearlDiver Patient Records Database using Current Procedural Terminology and International Classification of Diseases procedure codes, retrospective cohort analysis was carried out. This study involved 445,480 patients who underwent LF with at least 2-year follow-up and were followed up for 2 years. Of the patients, 2,762 underwent I&D. Using univariate analysis employing Pearson Chi-square and Student t-test, where appropriate (Table 1), patient demographics between cohorts were gathered. 2-year cumulative incidence (CI) between LF and I&D cohorts was calculated using Kaplan-Meier analysis (Fig. 1, 2, 3). Cox proportional hazards were employed to observe significant differences in CI rates (Table 2). Results: For patients who received I&D, 2-year CI depression (HR: 1.72; 95% CI: 1.49-1.99; P<0.001) and stress (HR: 1.35; 95% CI: 1.02-1.79; P=0.035) rates were significantly higher than for those who did not. There was no statistically significant difference in 2-year CI anxiety rates between cohorts (HR: 0.92; 95% CI: 0.58-1.46; P=0.719). Conclusions: In conclusion, 16.8% of patients developed new-onset depression 2 years following I&D, in comparison to 10.3% of those who underwent LF. Patients who underwent I&D following LF were significantly more likely to experience depression and stress. To mitigate negative mental health outcomes, mental health services should be available to patients who underwent surgery.

Depression State Correlates with Functional Recovery Following Elective Lumbar Spine Fusion.

OBJECTIVE: To determine how depression state impacts postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores and achievement of minimum clinically important difference (MCID) following lumbar fusion. Depression has been shown to negatively impact outcomes following numerous orthopedic surgeries. Situational and major clinical depression can differentially affect postoperative outcomes. METHODS: Adult patients undergoing elective 1-3 level lumbar fusion were reviewed. Patients with a formal diagnosis of major depression were classified as "clinically depressed" whereas patients with at least "mild" PROMIS Depression scores in the absence of formal depression diagnosis were deemed "situationally depressed." analysis of variance testing was used to assess differences within and between groups. Multivariate regression was used to identify features associated with the achievement of MCID. RESULTS: Two hundred patients were included. The average age was 65.9 ± 12.2 years. 75 patients (37.5%) were nondepressed, 66 patients (33.0%) were clinically depressed, and 59 patients (29.5%) were situationally depressed. Situationally depressed patients had worse preoperative physical function (PF) and pain interference (PI) scores and were more likely to have severe symptoms (P = 0.001, P = 0.001). All groups improved significantly from preoperative baseline scores. All groups met MCID PF at different rates, with highest proportion of situationally depressed reaching this metric (P = 0.03). Rates of achieving MCID PI were not significantly different between groups (P = 0.47). Situational depression was predictive of achieving MCID PF (P = 0.002) but not MCID PI. CONCLUSIONS: Our study investigated the relationship between depression and postoperative PROMIS scores and identified situationally depressed patients as having the worst preoperative impairment. Despite this, the situationally depressed cohort had the highest likelihood of achieving MCID PF, suggestive of a bidirectional relationship between lumbar degenerative disease and subclinical, situational depression. These findings may help guide preoperative counseling on expectations, and patient selection.