Sinonasal Packing is Not a Requisite for Successful Cerebrospinal Fluid Leak Repair.

Background Numerous methods have been described to repair nasal cerebrospinal fluid (CSF) leaks. Most studies have focused on optimizing CSF leak repair success, leading to closure rates of 90 to 95%. Objective This study aimed to determine if excellent reconstruction rates could be achieved without using sinonasal packing. Methods A prospective case series of 73 consecutive patients with various CSF leak etiologies and skull base defects was conducted to evaluate reconstruction success without sinonasal packing. The primary outcome measure was postoperative CSF leak. Secondary outcome measures were postoperative epistaxis requiring intervention in operating room or emergency department, infectious sinusitis, and 22-item sinonasal outcome test (SNOT-22) changes. Results Mean age was 54.5 years and 64% were female. Multilayered reconstructions were performed in 55.3% of cases, with collagen or bone epidural inlay grafts, and nasal mucosal grafts or nasoseptal flaps for onlay layers. Onlay-only reconstructions with mucosal grafts or nasoseptal flaps were performed in 44.7% of cases. Tissue sealants were used in all cases, and lumbar drains were used in 40.8% of cases. There were two initial failures (97.4% initial success), but both resolved with lumbar drains alone (no revision surgeries). There were no instances of postoperative epistaxis requiring intervention in the operating room or emergency department. Infectious sinusitis occurred in 2.7% of patients in the first 3 months postoperatively. SNOT-22 did not change significantly from preoperatively to first postoperative visits, then improved over time. Conclusion Nasal CSF leaks from various etiologies and defect sites were successfully repaired without using sinonasal packing, and patients experienced minimal sinonasal morbidity.

Characteristics and outcomes of patients undergoing lumbar spine surgery for axial back pain in the Michigan Spine Surgery Improvement Collaborative.

BACKGROUND CONTEXT: The indications for surgical intervention of axial back pain without leg pain for degenerative lumbar disorders have been limited in the literature, as most study designs allow some degree of leg symptoms in the inclusion criteria. PURPOSE: To determine the outcome of surgery (decompression only vs. fusion) for pure axial back pain without leg pain. STUDY DESIGN/SETTING: Prospectively collected data in the Michigan Spine Surgery Improvement Collaborative (MSSIC). PATIENT SAMPLE: Patients with pure axial back pain without leg pain underwent lumbar spine surgery for primary diagnoses of lumbar disc herniation, lumbar stenosis, and isthmic or degenerative spondylolisthesis ≤ grade II. OUTCOME MEASURES: Minimally clinically important difference (MCID) for back pain, Numeric Rating Scale of back pain, Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), MCID of PROMIS-PF, and patient satisfaction on the North American Spine Surgery Patient Satisfaction Index were collected at 90 days, 1 year, and 2 years after surgery. METHODS: Log-Poisson generalized estimating equation models were constructed with patient-reported outcomes as the independent variable, reporting adjusted risk ratios (RRadj). RESULTS: Of the 388 patients at 90 days, multi-level versus single level lumbar surgery decreased the likelihood of obtaining a MCID in back pain by 15% (RRadj=0.85, p=.038). For every one-unit increase in preoperative back pain, the likelihood for a favorable outcome increased by 8% (RRadj=1.08, p<.001). Of the 326 patients at 1 year, symptom duration > 1 year decreased the likelihood of a MCID in back pain by 16% (RRadj=0.84, p=.041). The probability of obtaining a MCID in back pain increased by 9% (RRadj=1.09, p<.001) for every 1-unit increase in baseline back pain score and by 14% for fusions versus decompression alone (RRadj=1.14, p=.0362). Of the 283 patients at 2 years, the likelihood of obtaining MCID in back pain decreased by 30% for patients with depression (RRadj=0.70, p<.001) and increased by 8% with every one-unit increase in baseline back pain score (RRadj=1.08, p<.001). CONCLUSIONS: Only the severity of preoperative back pain was associated with improvement in MCID in back pain at all time points, suggesting that surgery should be considered for selected patients with severe axial pain without leg pain. Fusion surgery versus decompression alone was associated with improved patient-reported outcomes at 1 year only, but not at the other time points.

Validation of the Benefits of Ambulation Within 8 Hours of Elective Cervical and Lumbar Surgery: A Michigan Spine Surgery Improvement Collaborative Study.

BACKGROUND: Early ambulation is considered a key element to Enhanced Recovery After Surgery protocol after spine surgery. OBJECTIVE: To investigate whether ambulation less than 8 hours after elective spine surgery is associated with improved outcome. METHODS: The Michigan Spine Surgery Improvement Collaborative database was queried to track all elective cervical and lumbar spine surgery between July 2018 and April 2021. In total, 7647 cervical and 17 616 lumbar cases were divided into 3 cohorts based on time to ambulate after surgery: (1) <8 hours, (2) 8 to 24 hours, and (3) >24 hours. RESULTS: For cervical cases, patients who ambulated 8 to 24 hours (adjusted odds ratio [aOR] 1.38; 95% CI 1.11-1.70; P = .003) and >24 hours (aOR 2.20; 95% CI 1.20-4.03; P = .011) after surgery had higher complication rate than those who ambulated within 8 hours of surgery. Similar findings were noted for lumbar cases with patients who ambulated 8 to 24 hours (aOR 1.31; 95% CI 1.12-1.54; P < .001) and >24 hours (aOR 1.96; 95% CI 1.50-2.56; P < .001) after surgery having significantly higher complication rate than those ambulated <8 hours after surgery. Analysis of secondary outcomes for cervical cases demonstrated that <8-hour ambulation was associated with home discharge, shorter hospital stay, lower 90-day readmission, and lower urinary retention rate. For lumbar cases, <8-hour ambulation was associated with shorter hospital stay, satisfaction with surgery, lower 30-day readmission, home discharge, and lower urinary retention rate. CONCLUSION: Ambulation within 8 hours after surgery is associated with significant improved outcome after elective cervical and lumbar spine surgery.

A Matched Cohort Analysis of Drain Usage in Elective Anterior Cervical Discectomy and Fusion: A Michigan Spine Surgery Improvement Collaborative (MSSIC) Study.

STUDY DESIGN: This is a retrospective, cohort analysis of multi-institutional database. OBJECTIVE: This study was designed to analyze the impact of drain use following elective anterior cervical discectomy and fusion (ACDF) surgeries. SUMMARY OF BACKGROUND DATA: After ACDF, a drain is often placed to prevent postoperative hematoma. However, there has been no high quality evidence to support its use with ACDF despite the theoretical benefits and risks of drain placement. METHODS: The Michigan Spine Surgery Improvement Collaborative database was queried to identify all patients undergoing elective ACDF between February 2014 and October 2019. Cases were divided into two cohorts based on drain use. Propensity-score matching was utilized to adjust for inherent differences between the two cohorts. Measured outcomes included surgical site hematoma, length of stay, surgical site infection, dysphagia, home discharge, readmission within 30 days, and unplanned reoperation. RESULTS: We identified 7943 patients during the study period. Propensity-score matching yielded 3206 pairs. On univariate analysis of matched cohorts, there were no differences in rate of postoperative hematoma requiring either return to OR or readmission. We noted patients with drains had a higher rate of dysphagia (4.6% vs. 6.3%; P = 0.003) and had longer hospital stay (P < 0.001). On multivariate analysis, drain use was associated with significantly increased length of stay (relative risk 1.23, 95% confidence interval [CI] 1.13-1.34; P < 0.001). There were no significant differences in other outcomes measured. CONCLUSION: Our analysis demonstrated that drain use is associated with significant longer hospital stay.Level of Evidence: 3.

Analysis of Factors Associated with Return-to-Work After Lumbar Surgery up to 2-Years Follow-up: A Michigan Spine Surgery Improvement Collaborative (MSSIC) Study.

STUDY DESIGN: Michigan Spine Surgery Improvement Collaborative (MSSIC) prospectively collects data on all patients undergoing operations for degenerative and/or deformity indications. OBJECTIVE: We aimed to identify which factors are significantly associated with return-to-work after lumbar surgery at long-term follow-up. SUMMARY OF BACKGROUND DATA: Prior publications have created a clinically relevant predictive model for return-to-work, wherein education, gender, race, comorbidities, and preoperative symptoms increased likelihood of return-to-work at 3 months after lumbar surgery. We sought to determine if these trends 1) persisted at 1 year and 2 years postoperatively; or 2) differed among preoperatively employed versus unemployed patients. METHODS: MSSIC was queried for all patients undergoing lumbar operations (2014-2019). All patients intended to return-to-work postoperatively. Patients were followed for up to 2 years postoperatively. Measures of association were calculated with multivariable generalized estimating equations. RESULTS: Return-to-work increased from 63% (3542/5591) at 90 days postoperatively to 75% (3143/4147) at 1 year and 74% (2133/2866) at 2 years postoperatively. Following generalized estimating equations, neither clinical nor surgical variables predicted return-to-work at all three time intervals: 90 days, 1 year, and 2 years postoperatively. Only socioeconomic factors reached statistical significance at all follow-up points. Preoperative employment followed by insurance status had the greatest associations with return-to-work. In a subanalysis of patients who were preoperatively employed, insurance was the only factor with significant associations with return-to-work at all three follow-up intervals. The return-to-work rates among unemployed patients at baseline increased from 29% (455/1100) at 90 days, 44% (495/608) at 1 year, and 46% (366/426) at 2 years postoperatively. The only two significant factors associated with return-to-work at all three follow-up intervals were Medicaid, as compared with private insurance, and male gender. CONCLUSION: In patients inquiring about long-term return-to-work after lumbar surgery, insurance status represents the important determinant of employment status.Level of Evidence: 2.

The association of patient education level with outcomes after elective lumbar surgery: a Michigan Spine Surgery Improvement Collaborative study.

OBJECTIVE: Socioeconomic factors have been shown to impact a host of healthcare-related outcomes. Level of education is a marker of socioeconomic status. This study aimed to investigate the relationship between patient education level and outcomes after elective lumbar surgery and to characterize any education-related disparities. METHODS: The Michigan Spine Surgery Improvement Collaborative registry was queried for all lumbar spine operations. Primary outcomes included patient satisfaction determined by the North American Spine Society patient satisfaction index, and reaching the minimum clinically important difference of Patient-Reported Outcomes Measurement Information System Physical Function score and return to work up to 2 years after surgery. Multivariate Poisson generalized estimating equation models reported adjusted risk ratios. RESULTS: A total of 26,229 lumbar spine patients had data available for inclusion in this study. On multivariate generalized estimating equation analysis all comparisons were done versus the high school (HS)/general equivalency development (GED)-level cohort. For North American Spine Society satisfaction scores after surgery the authors observed the following: at 90 days the likelihood of satisfaction significantly decreased by 11% (p < 0.001) among < HS, but increased by 1% (p = 0.52) among college-educated and 3% (p = 0.011) among postcollege-educated cohorts compared to the HS/GED cohort; at 1 year there was a decrease of 9% (p = 0.02) among < HS and increases of 3% (p = 0.02) among college-educated and 9% (p < 0.001) among postcollege-educated patients; and at 2 years, there was an increase of 5% (p = 0.001) among postcollege-educated patients compared to the < HS group. The likelihood of reaching a minimum clinically important difference of Patient-Reported Outcomes Measurement Information System Physical Function score at 90 days increased by 5% (p = 0.005) among college-educated and 9% (p < 0.001) among postcollege-educated cohorts; at 1 year, all comparison cohorts demonstrated significance, with a decrease of 12% (p = 0.007) among < HS, but an increase by 6% (p < 0.001) among college-educated patients and 14% (p < 0.001) among postcollege-educated compared to the HS/GED cohort; at 2 years, there was a significant decrease by 19% (p = 0.003) among the < HS cohort, an increase by 8% (p = 0.001) among the college-educated group, and an increase by 16% (p < 0.001) among the postcollege-educated group. For return to work, a significant increase was demonstrated at 90 days and 1 year when comparing the HS or less group with college or postcollege cohorts. CONCLUSIONS: This study demonstrated negative associations on all primary outcomes with lower levels of education. This finding suggests a potential disparity linked to education in elective spine surgery.

The role of postoperative antibiotic duration on surgical site infection after lumbar surgery.

OBJECTIVE: Despite a general consensus regarding the administration of preoperative antibiotics, poorly defined comparison groups and underpowered studies prevent clear guidelines for postoperative antibiotics. Utilizing a data set tailored specifically to spine surgery outcomes, in this clinical study the authors aimed to determine whether there is a role for postoperative antibiotics in the prevention of surgical site infection (SSI). METHODS: The Michigan Spine Surgery Improvement Collaborative registry was queried for all lumbar operations performed for degenerative spinal pathologies over a 5-year period from 2014 to 2019. Preoperative prophylactic antibiotics were administered for all surgical procedures. The study population was divided into three cohorts: no postoperative antibiotics, postoperative antibiotics ≤ 24 hours, and postoperative antibiotics > 24 hours. This categorization was intended to determine 1) whether postoperative antibiotics are helpful and 2) the appropriate duration of postoperative antibiotics. First, multivariable analysis with generalized estimating equations (GEEs) was used to determine the association between antibiotic duration and all-type SSI with adjusted odds ratios; second, a three-tiered outcome-no SSI, superficial SSI, and deep SSI-was calculated with multivariable multinomial logistical GEE analysis. RESULTS: Among 37,161 patients, the postoperative antibiotics > 24 hours cohort had more men with older average age, greater body mass index, and greater comorbidity burden. The postoperative antibiotics > 24 hours cohort had a 3% rate of SSI, which was significantly higher than the 2% rate of SSI of the other two cohorts (p = 0.004). On multivariable GEE analysis, neither postoperative antibiotics > 24 hours nor postoperative antibiotics ≤ 24 hours, as compared with no postoperative antibiotics, was associated with a lower rate of all-type postoperative SSIs. On multivariable multinomial logistical GEE analysis, neither postoperative antibiotics ≤ 24 hours nor postoperative antibiotics > 24 hours was associated with rate of superficial SSI, as compared with no antibiotic use at all. The odds of deep SSI decreased by 45% with postoperative antibiotics ≤ 24 hours (p = 0.002) and by 40% with postoperative antibiotics > 24 hours (p = 0.008). CONCLUSIONS: Although the incidence of all-type SSI was highest in the antibiotics > 24 hours cohort, which also had the highest proportions of risk factors, duration of antibiotics failed to predict all-type SSI. On multinomial subanalysis, administration of postoperative antibiotics for both ≤ 24 hours and > 24 hours was associated with decreased risk of only deep SSI but not superficial SSI. Spine surgeons can safely consider antibiotics for 24 hours, which is equally as effective as long-term administration for prophylaxis against deep SSI.

Preoperative Patient-Reported Outcomes Measurement Information System Global Health Scores Predict Patients Achieving the Minimal Clinically Important Difference in the Early Postoperative Time Period After Total Knee Arthroplasty.

INTRODUCTION: The patient-specific factors influencing postoperative improvement after total knee arthroplasty (TKA) are important considerations for the surgeon and patient. The primary purpose of this study was to determine which patient demographic factors influence the postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health (GH) scores. In addition, we aimed to compare the prognostic utility of preoperative PROMIS-GH scores and the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) in predicting postoperative improvement. METHODS: This retrospective cohort study of a consecutive series of patients who underwent primary, unilateral TKA analyzed prospectively collected KOOS-JR and PROMIS-GH surveys. PROMIS-GH includes physical health (PH) and mental health scores. Patient demographic and presurgical characteristics were evaluated for prognostic capability in predicting postoperative improvement in the PROMIS scores and achievement of the minimal clinically important difference (MCID). Receiver operating characteristic curves were used to understand the prognostic thresholds of the preoperative PROMIS score and KOOS-JR for predicting MCID achievement. RESULTS: A total of 872 patients were included. Although unadjusted analyses showed associations between patient demographic factors and PROMIS-PH scores, multivariable regression analysis for predictors of MCID achievement demonstrated that PROMIS-PH was the only significant preoperative variable. Receiver operating characteristic analysis revealed that the area under the curve of PROMIS-PH (0.70; 95% CI, 0.67 to 0.74) was less than that of the KOOS-JR (0.77; 95% CI, 0.73 to 0.81; P = 0.032). Sensitivity and specificity for achieving the MCID were maximized for preoperative PROMIS-PH scores of ≤ 38 (59% and 70%) and for preoperative KOOS-JR ≤ 51 (71% and 69%). CONCLUSIONS: Preoperative KOOS-JR and PROMIS-PH scores predict clinically meaningful improvement after TKA. The KOOS-JR has greater prognostic utility in the early postoperative period. LEVEL OF EVIDENCE: Level III, Prognostic Study.

Disparities in outcomes after spine surgery: a Michigan Spine Surgery Improvement Collaborative study.

OBJECTIVE: Most studies on racial disparities in spine surgery lack data granularity to control for both comorbidities and self-assessment metrics. Analyses from large, multicenter surgical registries can provide an enhanced platform for understanding different factors that influence outcome. In this study, the authors aimed to determine the effects of race on outcomes after lumbar surgery, using patient-reported outcomes (PROs) in 3 areas: the North American Spine Society patient satisfaction index, the minimal clinically important difference (MCID) on the Oswestry Disability Index (ODI) for low-back pain, and return to work. METHODS: The Michigan Spine Surgery Improvement Collaborative was queried for all elective lumbar operations. Patient race/ethnicity was categorized as Caucasian, African American, and "other." Measures of association between race and PROs were calculated with generalized estimating equations (GEEs) to report adjusted risk ratios. RESULTS: The African American cohort consisted of a greater proportion of women with the highest comorbidity burden. Among the 7980 and 4222 patients followed up at 1 and 2 years postoperatively, respectively, African American patients experienced the lowest rates of satisfaction, MCID on ODI, and return to work. Following a GEE, African American race decreased the probability of satisfaction at both 1 and 2 years postoperatively. Race did not affect return to work or achieving MCID on the ODI. The variable of greatest association with all 3 PROs at both follow-up times was postoperative depression. CONCLUSIONS: While a complex myriad of socioeconomic factors interplay between race and surgical success, the authors identified modifiable risk factors, specifically depression, that may improve PROs among African American patients after elective lumbar spine surgery.

Reducing Superfluous Opioid Prescribing Practices After Brain Surgery: It Is Time to Talk About Drugs.

BACKGROUND: Opioids are prescribed routinely after cranial surgery despite a paucity of evidence regarding the optimal quantity needed. Overprescribing may adversely contribute to opioid abuse, chronic use, and diversion. OBJECTIVE: To evaluate the effectiveness of a system-wide campaign to reduce opioid prescribing excess while maintaining adequate analgesia. METHODS: A retrospective cohort study of patients undergoing a craniotomy for tumor resection with home disposition before and after a 2-mo educational intervention was completed. The educational initiative was composed of directed didactic seminars targeting senior staff, residents, and advanced practice providers. Opioid prescribing patterns were then assessed for patients discharged before and after the intervention period. RESULTS: A total of 203 patients were discharged home following a craniotomy for tumor resection during the study period: 98 who underwent surgery prior to the educational interventions compared to 105 patients treated post-intervention. Following a 2-mo educational period, the quantity of opioids prescribed decreased by 52% (median morphine milligram equivalent per day [interquartile range], 32.1 [16.1, 64.3] vs 15.4 [0, 32.9], P < .001). Refill requests also decreased by 56% (17% vs 8%, P = .027) despite both groups having similar baseline characteristics. There was no increase in pain scores at outpatient follow-up (1.23 vs 0.85, P = .105). CONCLUSION: A dramatic reduction in opioids prescribed was achieved without affecting refill requests, patient satisfaction, or perceived analgesia. The use of targeted didactic education to safely improve opioid prescribing following intracranial surgery uniquely highlights the ability of simple, evidence-based interventions to impact clinical decision making, lessen potential patient harm, and address national public health concerns.

Risk Factors Associated with Symptomatic Deep Vein Thrombosis Following Elective Spine Surgery: A Case-Control Study.

BACKGROUND: Few studies provide insight into risk factors (RFs) associated with postoperative deep vein thrombosis (DVT) following elective spinal surgery. DVTs are detrimental in this population because of the risk of pulmonary embolization or surgical site hemorrhage with treatment. OBJECTIVE: Elective spine surgery patients have a low incidence of DVT, thus a case-control study was selected to investigate RFs associated with postoperative, symptomatic DVT. METHODS: Cases were matched to controls in a 1:2 ratio based on surgery type. Risk of having a prior DVT and choice of subcutaneous heparin dosing following surgery was analyzed in a multivariate regression model with other potentially confounding variables. RESULTS: A total of 195 patients were included in this study. Independent of patient age, history of DVT was associated with postoperative symptomatic DVT (odds ratio [OR], 4.09; 95% confidence interval [CI], 1.22-13.78). Two versus 3 times daily postoperative heparin dosing (OR, 1.56; 95% CI, 0.32-7.56), surgery length (OR, 1.32; 95% CI, 0.98-1.79), and patient age (OR, 1.04; 95% CI, 1.0-1.08) were not statistically significant, independent RFs. Older age and longer length of surgery trended toward association with DVT without reaching significance. Length of stay was increased from 3-5 days (P < 0.001) in DVT patients compared with controls. CONCLUSIONS: These results suggest that patients with a history of DVT undergoing elective spinal surgery are at higher risk of developing symptomatic DVT postoperatively resulting in significantly increased length of stay. Further studies on additional preoperative screening and medical optimization in elective spine surgery patients may help reduce the rate of symptomatic, postoperative DVT.

The economic impact of glioma survivorship: The cost of care from a patient perspective.

OBJECTIVE: We aimed to characterize the socioeconomic impact of glioma for patients with clinical and radiographic evidence of disease stability, using the standardized Medical Expenditure Panel Survey-Household Component (MEPS-HC). METHODS: The MEPS-HC questionnaire was used to investigate the degree of economic hardship referable to the patient's brain tumor and treatment. The questionnaire included demographic variables such as age at diagnosis, ethnicity, highest level of education, and annual household income. Descriptive statistics were used to characterize variables and between-group comparisons were evaluated using Fisher exact test. RESULTS: Of 127 prescreened patients, 89 of 107 eligible patients completed the survey. Pathology at diagnosis was predominantly low grade (60%). Most patients were insured at time of diagnosis (91%), married (76%), and employed (79%), with annual household incomes slightly higher than the national average. Despite this, nearly a quarter incurred debt referable to brain tumor care (24%), 53% required extended unpaid time off, and 46% retired or were no longer working. Financial burden and workforce morbidity were insensitive to tumor location, laterality, and annual household income. Patients with gross total resection at initial surgery were less likely to report ongoing limitations in daily activities (45% vs 83%, p = 0.004). CONCLUSIONS: Even in a population of stable, high-functioning glioma survivors, financial burden and workforce morbidity was ubiquitous across all tumor subtypes, treatment paradigms, and income levels.

Rates and risk factors associated with 90-day readmission following cervical spine fusion surgery: analysis of the Michigan Spine Surgery Improvement Collaborative (MSSIC) registry.

BACKGROUND CONTEXT: Hospital readmission rates are an increasingly important focus. Identifying patients at risk for readmission can help decrease those rates and thus decrease the overall cost of care. PURPOSE: We sought to report the rates and the risk factors associated with 90-day hospital readmission after degenerative cervical spine surgery via either an anterior or posterior approach. STUDY DESIGN: Retrospective review of prospectively collected database PATIENT SAMPLE: Michigan Spine Surgery Improvement Collaborative (MSSIC) registry OUTCOME MEASURES: Hospital readmission at 90 days METHODS: The MSSIC registry prospectively enrolls patients undergoing surgery for degenerative cervical spine disease. The registry was queried over a 4-year period to determine patient characteristics and risk factors associated with unplanned readmission at 90 days following degenerative cervical spine fusion surgery through either an anterior or posterior approach. Univariate and multivariate regression modeling was used to compare patient characteristics and odds of readmission. RESULTS: Of 3,762 patients who underwent an anterior approach, 202 (5.4%) were readmitted within 90 days. Of 693 patients who underwent a posterior approach, 85 (12.3%) were readmitted within 90 days. Risk factors associated with increased likelihood of readmission after the anterior approach were male sex (odds ratio [OR] 1.56, confidence interval [CI] 1.10-2.20), American Society of Anesthesiologists class >2 (OR 1.70, CI 1.26-2.30), and increased length of stay (OR 1.10, CI 1.03-1.19). Factors associated with decreased likelihood of readmission after the anterior approach were being independently ambulatory preoperatively (OR 0.59, CI 0.46-0.76) and holding private insurance (OR 0.67, CI 0.50-0.90). A history of previous spine surgery was associated with increased risk of readmission after the posterior approach (OR 1.76, CI 1.37-2.25). Pain was the most common single reason cited for readmission after either approach (9% anterior, 13% posterior). After an anterior approach, common surgical reasons for readmission include new radicular findings (8%), dysphagia (6%), and surgical site hematoma (5%), whereas common medical reasons include pneumonia (7%), infection outside the surgical site (6%), and an electrolyte issue. After a posterior approach, common surgical reasons for readmission after 90 days include surgical site infection (8%) and new radicular findings (6%), whereas common medical reasons include infection outside the surgical site (9%), urinary tract infection (8%), and an abdominal issue (8%). CONCLUSIONS: Analysis of a large multicentered, spine-specific database for elective cervical spine fusion surgery demonstrated an unplanned 90-day readmission rate of 5.4% for the anterior approach and 12.3% for the posterior approach. Factors associated with readmission for the anterior approach include male sex, American Society of Anesthesiologists class >2, increased length of stay, holding private insurance, and being ambulatory preoperatively. A history of previous spine surgery was associated with increased odds of readmission after the posterior approach.

The Preoperative Risks and Two-Year Sequelae of Postoperative Urinary Retention: Analysis of the Michigan Spine Surgery Improvement Collaborative (MSSIC).

OBJECTIVE: Although postoperative urinary retention (POUR) is common after spine surgery, the association of this adverse event with other morbidities and patient-reported outcomes is not fully understood. We sought to examine the sequelae of POUR after lumbar spine surgery. METHODS: The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a large prospective multicenter registry. MSSIC was queried with multivariate analysis for factors that are associated with POUR, the association of POUR with 90-day adverse events, and the effect of POUR on 2-year patient-reported outcomes and satisfaction. RESULTS: Multivariate analysis identified hardware revision (odds ratio [OR], 0.61), 1 operative level (OR, 0.74), and ambulation on postoperative day zero (OR, 0.65) to be protective for POUR. Factors associated with POUR included age (OR, 1.19), male gender (OR, 1.58), body mass index <25 (OR, 1.22), diabetes (OR, 1.28), coronary artery disease (OR, 1.20), fusion surgery (OR, 1.27), and longer surgery (OR, 1.11). Patients who had POUR were more likely to be readmitted, develop a urinary tract infection, and develop an infection (P < 0.001). POUR was associated with decreased likelihood of achieving Oswestry Disability Index minimal clinically important difference at 90 days (P < 0.001), but not at 1 year after surgery. POUR was associated with dissatisfaction with surgery at 90 days (P < 0.001), 1 year (P = 0.004), and 2 years after surgery (P = 0.011). CONCLUSIONS: POUR is common after lumbar spine surgery, and the demographic, diagnostic, and surgical factors that are associated with POUR are identified. POUR is associated with several adverse events, and patients who have POUR were less likely to be satisfied with surgery up to 2 years after surgery.

The Association of Preoperative Opioid Usage With Patient-Reported Outcomes, Adverse Events, and Return to Work After Lumbar Fusion: Analysis From the Michigan Spine Surgery Improvement Collaborative (MSSIC).

BACKGROUND: It is important to delineate the relationship between opioid use and spine surgery outcomes. OBJECTIVE: To determine the association between preoperative opioid usage and postoperative adverse events, patient satisfaction, return to work, and improvement in Oswestry Disability Index (ODI) in patients undergoing lumbar fusion procedures by using 2-yr data from a prospective spine registry. METHODS: Preoperative opioid chronicity from 8693 lumbar fusion patients was defined as opioid-naïve (no usage), new users (<6 wk), short-term users (6 wk-3 mo), intermediate-term users (3-6 mo), and chronic users (>6 mo). Multivariate generalized estimating equation models were constructed. RESULTS: All comparisons were to opioid-naïve patients. Chronic opioid users showed less satisfaction with their procedure at 90 d (Relative Risk (RR) 0.95, P = .001), 1 yr (RR 0.89, P = .001), and 2 yr (RR 0.89, P = .005). New opioid users were more likely to show improvement in ODI at 90 d (RR 1.25, P < .001), 1 yr (RR 1.17, P < .001), and 2 yr (RR 1.19, P = .002). Short-term opioid users were more likely to show ODI improvement at 90 d (RR 1.25, P < .001). Chronic opioid users were less likely to show ODI improvement at 90 d (RR 0.90, P = .004), 1 yr (RR 0.85, P < .001), and 2 yr (RR 0.80, P = .003). Chronic opioid users were less likely to return to work at 90 d (RR 0.80, P < .001). CONCLUSION: In lumbar fusion patients and when compared to opioid-naïve patients, new opioid users were more likely and chronic opioid users less likely to have improved ODI scores 2 yr after surgery. Chronic opioid users are less likely to be satisfied with their procedure 2 yr after surgery and less likely to return to work at 90 d. Preoperative opioid counseling is advised.

Ambulation on Postoperative Day #0 Is Associated With Decreased Morbidity and Adverse Events After Elective Lumbar Spine Surgery: Analysis From the Michigan Spine Surgery Improvement Collaborative (MSSIC).

BACKGROUND: While consistently recommended, the significance of early ambulation after surgery has not been definitively studied. OBJECTIVE: To identify the relationship between ambulation on the day of surgery (postoperative day (POD)#0) and 90-d adverse events after lumbar surgery. METHODS: The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a prospective multicenter registry of spine surgery patients. As part of routine postoperative care, patients either ambulated on POD#0 or did not. The 90-d adverse events of length of stay (LOS), urinary retention (UR), urinary tract infection (UTI), ileus, readmission, surgical site infection (SSI), pulmonary embolism/deep vein thrombosis (PE/DVT), and disposition to a rehab facility were measured. RESULTS: A total of 23 295 lumbar surgery patients were analyzed. POD#0 ambulation was associated with decreased LOS (relative LOS 0.83, P < .001), rehab discharge (odds ratio [OR] 0.52, P < .001), 30-d (OR 0.85, P = .044) and 90-d (OR 0.86, P = .014) readmission, UR (OR 0.73, P = 10), UTI (OR 73, P = .001), and ileus (OR 0.52, P < .001) for all patients. Significant improvements in LOS, rehab discharge, readmission, UR, UTI, and ileus were observed in subset analysis of single-level decompressions (4698 pts), multilevel decompressions (4079 pts), single-level fusions (4846 pts), and multilevel fusions (4413 pts). No change in rate of SSI or DVT/PE was observed for patients who ambulated POD#0. CONCLUSION: POD#0 ambulation is associated with a significantly decreased risk for several key adverse events after lumbar spine surgery. Decreasing the incidence of these outcomes would be associated with significant cost savings. As ambulation POD#0 is a modifiable factor in any patient's postoperative care following most spine surgery, it should be encouraged and incorporated into spine-related, enhanced-recovery-after-surgery programs.

Predictors of patient dissatisfaction at 1 and 2 years after lumbar surgery.

OBJECTIVE: As compensation transitions from a fee-for-service to pay-for-performance healthcare model, providers must prioritize patient-centered experiences. Here, the authors' primary aim was to identify predictors of patient dissatisfaction at 1 and 2 years after lumbar surgery. METHODS: The Michigan Spine Surgery Improvement Collaborative (MSSIC) was queried for all lumbar operations at the 1- and 2-year follow-ups. Predictors of patients' postoperative contentment were identified per the North American Spine Surgery (NASS) Patient Satisfaction Index, wherein satisfied patients were assigned a score of 1 ("the treatment met my expectations") or 2 ("I did not improve as much as I had hoped, but I would undergo the same treatment for the same outcome") and unsatisfied patients were assigned a score of 3 ("I did not improve as much as I had hoped, and I would not undergo the same treatment for the same outcome") or 4 ("I am the same or worse than before treatment"). Multivariable Poisson generalized estimating equation models were used to report adjusted risk ratios (RRadj). RESULTS: Among 5390 patients with a 1-year follow-up, 22% reported dissatisfaction postoperatively. Dissatisfaction was predicted by higher body mass index (RRadj =1.07, p < 0.001), African American race compared to white (RRadj = 1.51, p < 0.001), education level less than high school graduation compared to a high school diploma or equivalent (RRadj = 1.25, p = 0.008), smoking (RRadj = 1.34, p < 0.001), daily preoperative opioid use > 6 months (RRadj = 1.22, p < 0.001), depression (RRadj = 1.31, p < 0.001), symptom duration > 1 year (RRadj = 1.32, p < 0.001), previous spine surgery (RRadj = 1.32, p < 0.001), and higher baseline numeric rating scale (NRS)-back pain score (RRadj = 1.04, p = 0.002). Conversely, an education level higher than high school graduation, independent ambulation (RRadj = 0.90, p = 0.039), higher baseline NRS-leg pain score (RRadj = 0.97, p = 0.013), and fusion surgery (RRadj = 0.88, p = 0.014) decreased dissatisfaction.Among 2776 patients with a 2-year follow-up, 22% reported dissatisfaction postoperatively. Dissatisfaction was predicted by a non-white race, current smoking (RRadj = 1.26, p = 0.004), depression (RRadj = 1.34, p < 0.001), symptom duration > 1 year (RRadj = 1.47, p < 0.001), previous spine surgery (RRadj = 1.28, p < 0.001), and higher baseline NRS-back pain score (RRadj = 1.06, p = 0.003). Conversely, at least some college education (RRadj = 0.87, p = 0.035) decreased the risk of dissatisfaction. CONCLUSIONS: Both comorbid conditions and socioeconomic circumstances must be considered in counseling patients on postoperative expectations. After race, symptom duration was the strongest predictor of dissatisfaction; thus, patient-centered measures must be prioritized. These findings should serve as a tool for surgeons to identify at-risk populations that may need more attention regarding effective communication and additional preoperative counseling to address potential barriers unique to their situation.

Use of Patient Health Questionnaire-2 scoring to predict patient satisfaction and return to work up to 1 year after lumbar fusion: a 2-year analysis from the Michigan Spine Surgery Improvement Collaborative.

OBJECTIVE: The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a prospective, longitudinal, multicenter, quality-improvement collaborative. Using MSSIC, the authors sought to identify the relationship between a positive Patient Health Questionnaire-2 (PHQ-2) screening, which is predictive of depression, and patient satisfaction, return to work, and achieving Oswestry Disability Index (ODI) minimal clinically important difference (MCID) scores up to 2 years after lumbar fusion. METHODS: Data from a total of 8585 lumbar fusion patients were analyzed. Patient satisfaction was measured by the North American Spine Society patient satisfaction index. A positive PHQ-2 score is one that is ≥ 3, which has an 82.9% sensitivity and 90.0% specificity in detecting major depressive disorder. Generalized estimating equation models were constructed; variables tested include age, sex, race, past medical history, severity of surgery, and preoperative opioid usage. RESULTS: Multivariate analysis was performed. Patients with a positive PHQ-2 score (i.e., ≥ 3) were less likely to be satisfied after lumbar fusion at 90 days (relative risk [RR] 0.93, p < 0.001), 1 year (RR 0.92, p = 0.001), and 2 years (RR 0.92, p = 0.028). A positive PHQ-2 score was also associated with decreased likelihood of returning to work at 90 days (RR 0.76, p < 0.001), 1 year (RR 0.85, p = 0.001), and 2 years (RR 0.82, p = 0.031). A positive PHQ-2 score was predictive of failure to achieve an ODI MCID at 90 days (RR 1.07, p = 0.005) but not at 1 year or 2 years after lumbar fusion. CONCLUSIONS: A multivariate analysis based on information from a large, multicenter, prospective database on lumbar fusion patients was performed. The authors found that a positive score (≥ 3) on the PHQ-2, which is a simple and accurate screening tool for depression, predicts an inability to return to work and worse satisfaction up to 2 years after lumbar fusion. Depression is a treatable condition, and so in the same way that patients are medically optimized before surgery to decrease postoperative morbidity, perhaps patients should have preoperative psychiatric optimization to improve postoperative functional outcomes.

Patient Demographic and Surgical Factors that Affect Completion of Patient-Reported Outcomes 90 Days and 1 Year After Spine Surgery: Analysis from the Michigan Spine Surgery Improvement Collaborative (MSSIC).

BACKGROUND: The Michigan Spine Surgery Improvement Collaborative is a statewide multicenter quality improvement registry. Because missing data can affect registry results, we used MSSIC to find demographic and surgical characteristics that affect the completion of patient-reported outcomes (PROs) at 90 days and 1 year. METHODS: A total of 24,404 patients who had lumbar surgery (17,813 patients) or cervical surgery (6591 patients) were included. Multivariate logistic regression models of patient disease were constructed to identify risk factors for failure to complete scheduled PRO surveys. RESULTS: Patients ≥65 years old and female patients were both more likely to respond at 90 days and 1 year. Increasing education was associated with greater response rate at 90 days and 1 year. Whites and African Americans had no differences in response rates. Calling provided the highest response rate at 90 days and 1 year. For cervical spine patients, only discharge to rehabilitation increased completion rates, at 90 days but not 1 year. For lumbar spine patients, spondylolisthesis or stenosis (vs. herniated disc) had a greater response rate at 1 year. Patients with leg (vs. back) pain had a greater response only at 1 year. Patients with multilevel surgery had an increased response at 1 year. Patients who underwent fusion were more likely to respond at 90 days, but not 1 year. Discharge to rehabilitation increased response at 90 days and 1 year. CONCLUSIONS: A multivariate analysis from a multicenter prospective database identified surgical factors that affect PRO follow-up, up to 1 year. This information can be helpful for imputing missing PRO data and could be used to strengthen data derived from large prospective databases.

Adverse events and their risk factors 90 days after cervical spine surgery: analysis from the Michigan Spine Surgery Improvement Collaborative.

OBJECTIVEThe Michigan Spine Surgery Improvement Collaborative (MSSIC) is a statewide, multicenter quality improvement initiative. Using MSSIC data, the authors sought to identify 90-day adverse events and their associated risk factors (RFs) after cervical spine surgery.METHODSA total of 8236 cervical spine surgery cases were analyzed. Multivariable generalized estimating equation regression models were constructed to identify RFs for adverse events; variables tested included age, sex, diabetes mellitus, disc herniation, foraminal stenosis, central stenosis, American Society of Anesthesiologists Physical Classification System (ASA) class > II, myelopathy, private insurance, anterior versus posterior approach, revision procedures, number of surgical levels, length of procedure, blood loss, preoperative ambulation, ambulation day of surgery, length of hospital stay, and discharge disposition.RESULTSNinety days after cervical spine surgery, adverse events identified included radicular findings (11.6%), readmission (7.7%), dysphagia requiring dietary modification (feeding tube or nothing by mouth [NPO]) (6.4%), urinary retention (4.7%), urinary tract infection (2.2%), surgical site hematoma (1.1%), surgical site infection (0.9%), deep vein thrombosis (0.7%), pulmonary embolism (0.5%), neurogenic bowel/bladder (0.4%), myelopathy (0.4%), myocardial infarction (0.4%), wound dehiscence (0.2%), claudication (0.2%), and ileus (0.2%). RFs for dysphagia included anterior approach (p < 0.001), fusion procedures (p = 0.030), multiple-level surgery when considering anterior procedures only (p = 0.037), and surgery duration (p = 0.002). RFs for readmission included ASA class > II (p < 0.001), while preoperative ambulation (p = 0.001) and private insurance (p < 0.001) were protective. RFs for urinary retention included increasing age (p < 0.001) and male sex (p < 0.001), while anterior-approach surgery (p < 0.001), preoperative ambulation (p = 0.001), and ambulation day of surgery (p = 0.001) were protective. Preoperative ambulation (p = 0.010) and anterior approach (p = 0.002) were protective of radicular findings.CONCLUSIONSA multivariate analysis from a large, multicenter, prospective database identified the common adverse events after cervical spine surgery, along with their associated RFs. This information can lead to more informed surgeons and patients. The authors found that early mobilization after cervical spine surgery has the potential to significantly decrease adverse events.