Enhanced Recovery After Surgery Trends in Adult Spine Surgery: A Systematic Review.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) is a multimodal, multidisciplinary approach to optimizing the postsurgical recovery process through preoperative, perioperative, and postoperative interventions. ERAS protocols are emerging quickly within orthopedic spine surgery, yet there is a lack of consensus on optimal ERAS practices. OBJECTIVE: The aim of this systematic review is to identify and discuss the trends in spine ERAS protocols and the associated outcomes. METHODS: A literature search on PubMed was conducted to identify clinical studies that implemented ERAS protocols for various spine procedures in the adult population. The search included English-language literature published through December 2019. Additional sources were retrieved from the reference lists of key studies. Studies that met inclusion criteria were identified manually. Data regarding the study population, study design, spine procedures, ERAS interventions, and associated outcome metrics were extracted from each study that met inclusion criteria. RESULTS: Of the 106 studies identified from the literature search, 22 studies met inclusion criteria. From the ERAS protocols in these studies, common preoperative elements include patient education and modified preoperative nutrition regimens. Perioperative elements include multimodal analgesia and minimally invasive surgery. Postoperative elements include multimodal pain management and early mobilization/rehabilitation/nutrition regimens. Outcomes from ERAS implementation include significant reductions in length of stay, cost, and opioid consumption. Although these trends were observed, there remained great variability among the ERAS protocols, as well as in the reported outcomes. CONCLUSIONS: ERAS may improve cost-effectiveness to varying degrees for spinal procedures. Specifically, the use of multimodal analgesia may reduce overall opioid consumption. However, the benefits of ERAS likely will vary based on the specific procedure. CLINICAL RELEVANCE: This review contributes to the assessment of ERAS protocol implementation in the field of adult spine surgery.

Evaluation of Health-related Quality of Life Improvement in Patients Undergoing Spine Versus Adult Reconstructive Surgery.

STUDY DESIGN: Retrospective analysis of outcomes in single-level spine and primary hip and knee arthroplasty patients. OBJECTIVE: The aim of this study was to compare baseline and postoperative outcomes in patients undergoing spine surgery procedures with total hip arthroplasty (THA) and total knee arthroplasty (TKA) to further define outcomes in orthopedic surgery. SUMMARY OF BACKGROUND DATA: Computer-adaptive Patient Reported Outcome Information System (PROMIS) allows for standardized assessment of the health-related quality of life across different disease states. METHODS: Patients who underwent spine surgery (anterior cervical discectomy and fusion, cervical disc replacement, lumbar laminectomy, microscopic lumbar discectomy, transforaminal lumbar interbody fusion or adult reconstruction surgery [THA, TKA]) were grouped. Mean Charlson Comorbidity Index (CCI), Baseline (BL), and 6-month PROMIS scores of physical function, pain interference, and pain intensity were determined. Paired t tests compared differences in CCI, BL, 6 months, and change in PROMIS scores for spine and adult reconstruction procedures. RESULTS: A total of 304 spine surgery patients (age = 58.1 ±â€Š15.6; 42.9% female) and 347 adult reconstruction patients (age = 62.9 ±â€Š11.8; 54.1% Female) were compared. Spine surgery groups had more disability and pain at baseline than adult reconstruction patients according to physical function ([21.0, 22.2, 9.07, 12.6, 10.4] vs. [35.8, 35.0], respectively, P < 0.01), pain interference ([80.1, 74.1, 89.6, 92.5, 90.6] vs. [64.0, 63.9], respectively, P < 0.01), and pain intensity ([53.0, 53.1, 58.3, 58.5, 56.1] vs. [53.4, 53.8], respectively, P < 0.01). At 6 months, spine surgery patients remained more disabled and had more pain compared to adult reconstruction patients. Over the 6-month timespan, spine patients experienced greater improvements than adult reconstruction patients in terms of physical function ([+8.7, +22.2, +9.7, +12.9, +12.1] vs. [+5.3, +3.9], respectively, P < 0.01) and pain interference scores ([-15.4,-28.1, -14.7, -13.1, -12.3] vs. [-8.3, -6.0], respectively, P < 0.01). CONCLUSION: Spinal surgery patients had lower BL and 6-month PROMIS scores, but greater relative improvement in PROMIS scores compared to adult reconstruction patients. LEVEL OF EVIDENCE: 3.

Hospital-acquired conditions occur more frequently in elective spine surgery than for other common elective surgical procedures.

Hospital-acquired conditions (HACs) have been the focus of recent initiatives by the Centers for Medicare and Medicaid Services in an effort to improve patient safety and outcomes. Spine surgery can be complex and may carry significant comorbidity burden, including so called "never events." The objective was to determine the rates of common HACs that occur within 30-days post-operatively for elective spine surgeries and compare them to other common surgical procedures. Patients: >18 y/o undergoing elective spine surgery were identified in the American College of Surgeons' NSQIP database from 2005 to 2013. Patients were stratified by whether they experienced >1 HAC, then compared to those undergoing other procedures including bariatric surgery, THA and TKA. Of the 90,551 spine surgery patients, 3021 (3.3%) developed at least one HAC. SSI was the most common (1.4%), followed by UTI (1.3%), and VTE (0.8%). Rates of HACs in spine surgery were significantly higher than other elective procedures including bariatric surgery (2.8%) and THA (2.8%) (both p < 0.001). Spine surgery and TKA patients had similar rates of HACs(3.3% vs 3.4%, p = 0.287), though spine patients experienced higher rates of SSI (1.4%vs0.8%, p < 0.001) and UTI (1.3%vs1.1%, p < 0.001) but lower rates of VTE (0.8%vs1.6%, p < 0.001). Spine surgery patients had lower rates of HACs overall (3.3%vs5.9%) when compared to cardiothoracic surgery patients (p < 0.001). When compared to other surgery types, spine procedures were associated with higher HACs than bariatric surgery patients and knee and hip arthroplasties overall but lower HAC rates than patients undergoing cardiothoracic surgery.

Prevalence of Risk Factors for Hospital-Acquired Venous Thromboembolism in Neurosurgery and Orthopedic Spine Surgery Patients.

BACKGROUND: Hospital-acquired venous thromboembolisms (HA-VTE) are a significant source of morbidity and mortality in spine surgery patients. The purpose of this study was to review HA-VTE rates at our institution and evaluate the prevalence of known risk factors in patients who developed HA-VTE among both neurosurgical and orthopedic spine surgeries. METHODS: Retrospective chart reviews were conducted of all spine surgery patients from January 1, 2013, to July 31, 2017, to evaluate rates of HA-VTE and prevalence of known HA-VTE risk factors among these patients. Univariate and multivariate logistic regression analysis for categorical variables and independent Student t test for continuous variables were utilized with significance set at P < .05. RESULTS: The overall HA-VTE rate was 0.94% (0.61% orthopedic, 1.87% neurosurgery). Patients with VTEs had higher rates of thoracic procedure (P = .002), posterior approach (P = .001), diagnosis of fracture (P = .013) or flatback syndrome (P = .028), neurosurgery division (P < .001), and diagnosis-related group (DRG) of noncervical malignancy (P = .001). Patients with VTEs had lower rates of cervical procedure (P < .001), diagnosis of herniated nucleus pulposus (P = .006) and degenerative disc disease (P = .001), and DRG of cervical spine fusion (P < .001). In the patients who sustained VTE, the neurosurgical patients had higher rates of active cancer (22.86% vs 0%, P = .004) and age >60 (80% vs 50%, P < .001), and orthopedic patients had higher estimated blood loss (EBL) (2436 ml vs 1176 mL, P = .006) and rates of anterior-posterior surgery (22.58% vs 0%, P = .003). Neurosurgery department, diagnosis of fracture, and DRG of noncervical malignancy were found to be significant independent risks for developing HA-VTE. Cervical procedures were independently associated with significantly lower risk. Postoperative anticoagulation initiated sooner in neurosurgery patients (postoperative day 1.26 vs 3.19, P < .001). CONCLUSIONS: The overall HA-VTE rate at our institution was 0.94% (0.61% orthopedic, 1.87% neurosurgery). In patients who sustained VTE, neurosurgical patients had higher rates of active cancer and age >60 years, and orthopedic patients had higher EBL and rates of anterior-posterior surgery. This highlights the different patient populations between the 2 departments and the need for individualized thromboprophylaxis regimens. LEVEL OF EVIDENCE: 4.

MRI Radiological Predictors of Requiring Microscopic Lumbar Discectomy After Lumbar Disc Herniation.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To investigate radiological differences in lumbar disc herniations (herniated nucleus pulposus [HNP]) between patients receiving microscopic lumbar discectomy (MLD) and nonoperative patients. METHODS: Patients with primary treatment for an HNP at a single academic institution between November 2012 to March 2017 were divided into MLD and nonoperative treatment groups. Using magnetic resonance imaging (MRI), axial HNP area; axial canal area; HNP canal compromise; HNP cephalad/caudal migration and HNP MRI signal (black, gray, or mixed) were measured. T test and chi-square analyses compared differences in the groups, binary logistic regression analysis determined odds ratios (ORs), and decision tree analysis compared the cutoff values for risk factors. RESULTS: A total of 285 patients (78 MLD, 207 nonoperative) were included. Risk factors for MLD treatment included larger axial HNP area (P < .01, OR = 1.01), caudal migration, and migration magnitude (P < .05, OR = 1.90; P < .01, OR = 1.14), and gray HNP MRI signal (P < .01, OR = 5.42). Cutoff values for risks included axial HNP area (70.52 mm2, OR = 2.66, P < .01), HNP canal compromise (20.0%, OR = 3.29, P < .01), and cephalad/caudal migration (6.8 mm, OR = 2.43, P < .01). MLD risk for those with gray HNP MRI signal (67.6% alone) increased when combined with axial HNP area >70.52 mm2 (75.5%, P = .01) and HNP canal compromise >20.0% (71.1%, P = .05) cutoffs. MLD risk in patients with cephalad/caudal migration >6.8 mm (40.5% alone) increased when combined with axial HNP area and HNP canal compromise (52.4%, 50%; P < .01). CONCLUSION: Patients who underwent MLD treatment had significantly different axial HNP area, frequency of caudal migration, magnitude of cephalad/caudal migration, and disc herniation MRI signal compared to patients with nonoperative treatment.

Static and Dynamic Balance in Adults Undergoing Lumbar Spine Surgery: Screening and Prediction of Postsurgical Outcomes.

INTRODUCTION: Balance and fall risk before and after lumbar surgery was assessed to determine whether balance at baseline predicts long-term postsurgical outcomes. METHODS: Forty-three patients in the United States and Israel performed the single-leg stance (SLS) test, four square step test (FSST), and 8-foot up-and-go (8FUG) test before and 2 to 4 months after lumbar spine surgery. They completed the Oswestry Disability Index (ODI) and pain rating before and 12 months after lumbar surgery. RESULTS: From baseline to follow-up, the SLS time was 3.74 seconds longer (P = 0.01), the FSST time was 1.94 seconds faster (P < 0.001), and the 8FUG time was 1.55 seconds faster (P = 0.02). Before surgery, 26% of the patients were considered high fall risk according to the FSST and 51% according to the 8FUG. Postsurgery, all patients could complete the physical tests, but 26% remained at high fall risk according to the 8FUG and 7.5% according to the FSST. The three physical measures together explained 30% of the variance in postsurgical ODI scores (P = 0.02). Age was not correlated with performance. DISCUSSION: Risk of falling is higher than surgeons suspect. Balance tests (ie, SLS, FSST, and 8FUG) are quick and easy to administer. The findings support the importance of screening for balance and fall risk in adults undergoing lumbar spine surgery.

Preoperative MRI predictors of health-related quality of life improvement after microscopic lumbar discectomy.

BACKGROUND: Lumbar herniated nucleus pulposus (HNP) is a common spinal pathology often treated by microscopic lumbar discectomy (MLD), though prior reports have not demonstrated which preoperative MRI factors may contribute to significant clinical improvement after MLD. PURPOSE: To analyze the MRI characteristics in patients with HNP that predict meaningful clinical improvement in health-related quality of life scores (HRQoL) after MLD. STUDY DESIGN/SETTING: Retrospective clinical and radiological study of patients undergoing MLD for HNP at a single institution over a 2-year period. PATIENT SAMPLE: Eighty-eight patients receiving MLD treatment for HNP. OUTCOME MEASURES: Cephalocaudal Canal Migration; Canal & HNP Anterior-Posterior (AP) Lengths and Ratio; Canal & HNP Axial Areas and Ratio; Hemi-Canal & Hemi-HNP Axial Areas and Ratio; Disc appearance (black, gray, or mixed); Baseline (BL); and 3-month (3M) postoperative HRQoL scores. METHODS: Patients >18 years old who received MLD for HNP with BL and 3M HRQoL scores of PROMIS (Physical Function, Pain Interference, and Pain Intensity), ODI, VAS Back, and VAS Leg scores were included. HNP and spinal canal measurements of cephalocaudal migration, AP length, area, hemi-area, and disc appearance were performed using T2 axial and sagittal MRI. HNP measurements were divided by corresponding canal measurements to calculate AP, Area, and Hemi-Area ratios. Using known minimal clinically important differences (MCID) for each ΔHRQoL score, patients were separated into two groups based on whether they reached MCID (MCID+) or did not reach MCID (MCID-). The MCID for PROMIS pain intensity was calculated using a decision tree. A linear regression illustrated correlations between PROMIS vs ODI and VAS Back/Leg scores. Independent t-tests and chi-squared tests were utilized to investigate significant differences in HNP measurements between the MCID+ and MCID- groups. RESULTS: There were 88 MLD patients included in the study (Age=44.6±14.9, 38.6% female). PROMIS pain interference and pain intensity were strongly correlated with ODI and VAS Back/Leg (R≥0.505), and physical function correlated with ODI and VAS Back/Leg (R=-0.349) (all p<.01). The strongest MRI predictors of meeting HRQoL MCID were gray disc appearance, HNP area (>116.6 mm2), and Hemi-Area Ratio (>51.8%). MCID+ patients were 2.7 times more likely to have a gray HNP MRI signal than a mixed or black HNP MRI signal in five out of six HRQoL score comparisons (p<.025). MCID+ patients had larger HNP areas than MCID- patients had in five out of six HRQoL score comparisons (116.6 mm2±46.4 vs 90.0 mm2±43.2, p<.04). MCID+ patients had a greater Hemi-Area Ratio than MCID- patients had in four out of six HRQoL score comparisons (51.8%±14.7 vs 43.9%±14.9, p<.05). CONCLUSIONS: Patients who met MCID after MLD had larger HNP areas and larger Hemi-HNP Areas than those who did not meet MCID. These patients were also 2.7× more likely to have a gray MRI signal than a mixed or black MRI signal. When accounting for HNP area relative to canal area, patients who met MCID had greater Hemi-HNP canal occupation than patients who did not meet MCID. The results of this study suggest that preoperative MRI parameters can be useful in predicting patient-reported improvement after MLD.

The effect of vascular approach surgeons on perioperative complications in lateral transpsoas lumbar interbody fusions.

BACKGROUND CONTEXT: Lateral lumbar interbody fusion (LLIF) is a popular technique used in spine surgery. It is minimally invasive, provides indirect decompression, and allows for coronal plane deformity correction. Despite these benefits, the approach to LLIF has been linked to complications associated with the lumbosacral plexus and vascular anatomy. As a result, vascular surgeons may be recruited for the exposure portion of the procedure. PURPOSE: The purpose of this study was to compare exposure-related complication and postoperative (postop) neuropraxia rates between exposure (EXP) and spine surgeon only (SSO) groups while performing the approach for LLIF. STUDY DESIGN/SETTING: Retrospective analysis of patients treated at a single institution. PATIENT SAMPLE: Patients undergoing LLIF procedures between 2012 and 2018. OUTCOME MEASURES: Operative time, estimated blood loss, fluoroscopy, length of stay (LOS), intra- and postoperative complications, and physiologic measures including pre- and postoperative motor examinations and unresolved neuropraxia. METHODS: Patients who underwent LLIF were separated into EXP and SSO groups based on the presence or absence of vascular/general surgeon during the approach. The entire clinical history of patients with a decrease in pre- and postop motor examination was reviewed for the presence of neuropraxia. All other intra- and postop exposure-related complications were recorded for comparison. Propensity score matching (PSM) was performed to account for age, Charlson Comorbidity Index (CCI) percentage of LLIFs including L4-L5, and number of levels fused. Independent t test and chi-square analyses were used to identify significant differences between EXP and SSO groups. Statistical significance was set at p<.05. RESULTS: Two hundred and seventy-five patients underwent LLIF procedures, 155 SSO and 120 EXP. Postoperatively, 26 patients (11.1%) experienced a drop in any Medical Research Council (MRC) score, and two patients (0.7%) experienced unresolved quadriceps palsies. The mean recovery time for MRC scores was 84.4 days. Other complications included 2 pneumothoraces (0.7%), 1 iliac vein injury (0.4%), 14 cases of ileus (5.1%), 3 pulmonary emboli (1.1%), 2 deep vein thrombosis (0.7%), 3 cases of abdominal wall paresis (1.1%), and one abdominal hematoma (0.4%). After PSM, demographics including age, gender, body mass index, CCI, levels fused, and operative time were similar between cohorts. Twenty patients had changes in pre- to postop motor scores (SSO 9.4%, EXP 12.4%, p>.05). Iliopsoas motor scores decreased at the highest rate (EXP 12.4%, SSO 8.2%, p>.05) followed by quadriceps (EXP 5.2%, SSO 4.7%, p>.05). One SSO patient's postop course was complicated by a foot drop but returned to baseline within 1 year. One patient in EXP group developed an unresolved quadriceps palsy (EXP 1.0%, SSO 0.0%, p>.05). Intraoperative exposure complications included one pneumothorax (EXP 1.0%, SSO 0.0%, p>.05). There were no differences in PE/DVT, Ileus, or LOS. In the EXP cohort, three patients experienced abdominal wall paresis (EXP 2.9%, SSO 0.00%, p=.246). CONCLUSIONS: Comparing the LLIF exposures performed by EXP and SSO, we found no significant difference in the rates of complications. Additional research is needed to determine the etiology of the abdominal wall complications. In conclusion, neuropraxia- and approach-related complications are similarly low between exposure and spine surgeons.

Three-dimensional printing in spine surgery: a review of current applications.

In recent years, the use of three-dimensional printing (3DP) technology has gained traction in orthopedic spine surgery. Although research on this topic is still primarily limited to case reports and small cohort studies, it is evident that there are many avenues for 3DP innovation in the field. This review article aims to discuss the current and emerging 3DP applications in spine surgery, as well as the challenges of 3DP production and limitations in its use. 3DP models have been presented as helpful tools for patient education, medical training, and presurgical planning. Intraoperatively, 3DP devices may serve as patient-specific surgical guides and implants that improve surgical outcomes. However, the time, cost, and learning curve associated with constructing a 3DP model are major barriers to widespread use in spine surgery. Considering the costs and benefits of 3DP along with the varying risks associated with different spine procedures, 3DP technology is likely most valuable for complex or atypical spine disorder cases. Further research is warranted to gain a better understanding of how 3DP can and will impact spine surgery.

Initial Single-Institution Experience With a Novel Robotic-Navigation System for Thoracolumbar Pedicle Screw and Pelvic Screw Placement With 643 Screws.

BACKGROUND: Robotic-guided navigation systems for pedicle screw placement has gained recent interest to ensure accuracy and safety and diminish radiation exposure. There have been no published studies using a new combined robotics and navigation system (Globus ExcelsiusGPS system). The purpose of this study was to demonstrate safety with this system. METHODS: This is a case series of consecutive patients at a single institution from February 1, 2018, to August 31, 2018. All patients who had planned placement of thoracic and lumbar pedicle screws using the combined robotics-navigation system were included. Chart review was performed for operative details. A subgroup analysis was performed on patients with postoperative computed tomography (CT) scans to assess screw placement accuracy using the Gertzbein and Robbins system. Acceptable pedicle screw position was defined as grade A or B. RESULTS: One hundred six patients were included, with 636 pedicle screws, 6 iliac screws, and 1 S2AI screw. Five cases were aborted for technical issues. In the remaining 101 patients, 88 patients had screws placed using preoperative CT planning and 13 patients using intraoperative fluoroscopy planning. All screws except for 5 pedicle screws in 2 patients were placed successfully using the robot (99%). These 5 pedicle screws were placed by converting to a fluoro-guided technique without robotic assistance. Eighty-six patients had screws placed using a percutaneous technique, and 15 patients had screws placed using an open technique. Ninety-eight patients underwent interbody placement: 28 anterior lumbar interbody fusions (ALIFs), 12 lateral lumbar interbody fusions (LLIFs), and 58 transforaminal lumbar interbody fusions (TLIFs). All ALIFs and LLIFs were performed prior to placement of the screws. Four LIF patients had screws placed in the lateral position. No patients had screw-related complications intraoperatively or postoperatively, and no patients returned to the operating room for screw revision. Thirteen patients underwent postoperative CT for various reasons. Of the 66 pedicle screws that were examined with postoperative CT, all screws (100%) had acceptable position. CONCLUSION: This study demonstrates that the combined robotics and navigation system is a novel technology that can be utilized to place pedicle screws and pelvic screws safely and has the potential to reduce screw-related complications. LEVEL OF EVIDENCE: 4 (case series).

Same-Day Anterior Cervical Discectomy and Fusion-Our Protocol and Experience: Same-Day Discharge After Anterior Cervical Discectomy and Fusion in Suitable Patients has Similarly Low Readmission Rates as Admitted Patients.

BACKGROUND: Outpatient anterior cervical discectomy and fusion (ACDF) is performed frequently, with studies demonstrating similar complication and readmission rates compared to traditional admission. Advantages include cost effectiveness, as well as lower risk of nosocomial infections and medical errors, which lead to quicker recovery and higher patient satisfaction. Protocols are needed to ensure that outpatient ACDF occurs safely. The objective of this study was to develop and implement a protocol with patient selection and discharge criteria for patients undergoing same-day discharge (SDD) ACDF and assess readmission rates. METHODS: A retrospective chart review was performed to identify patients undergoing 1 or 2 level primary ACDF between March 2016 and March 2017 who were eligible for SDD according to the institutional protocol (Figure 1, Table 2). Patients with identical surgery and discharge dates were grouped as SDD, and admitted patients were grouped as same-day admission (SDA). Using our electronic health record's analytics, readmissions in the 90-day postoperative period were identified. RESULTS: Of the 434 patients identified, 126 patients were SDD, and 308 were SDA. Baseline characteristics such as age, operative time, and time in the recovery room were significantly different between the 2 groups (Table 2). The average length of stay of admitted patients was 1.48 days, with 77% discharged on postoperative day 1. There was an overall, noninferior readmission rate of 0.8% in the SDD group compared to 0.6% in the SDA group (P = .86). CONCLUSIONS: The results of this study support the feasibility of outpatient ACDF and add a patient selection and discharge criteria to the literature. Proper identification of suitable patients using our protocol results in a noninferior readmission rate, allowing surgeons to continue to safely perform these surgeries with a low readmission rate. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: SDD is safe in the appropriate patient population.

Association Between Nonmodifiable Demographic Factors and Patient Satisfaction Scores in Spine Surgery Clinics.

The Press Ganey survey is the most widely used instrument for measuring patient satisfaction. Understanding the factors that influence these surveys may permit better use of survey results and may direct interventions to increase patient satisfaction. Press Ganey Clinician and Group Consumer Assessment of Healthcare Providers and Systems surveys administered to ambulatory spine surgery clinic patients within a large tertiary care network from May 2016 to September 2017 were retrospectively reviewed. Mean comparison testing was performed to measure associations between patient demographics and responses to "overall provider rating" and "recommend this provider's office" survey questions. Mean difference to achieve significance was set at α<0.05. A multivariate analysis was performed to determine independent factors. A total of 1400 survey responses from the offices of 11 orthopedic spine surgeons were included. Patients 18 to 34 years old had significantly lower responses to the overall provider rating question than older patients (P<.001), and increasing patient age was correlated with improved ratings. Highest education level was inversely correlated with satisfaction scores, with patients who had attained graduate level education having the lowest satisfaction scores (P=.001). Those with commercial insurance had significantly lower ratings for recommend this provider's office (P=.042) and overall provider rating (P=.022) questions than those with other insurance types. Patients administered the survey on paper had significantly lower ratings than those administered the survey online (P=.006). Provider ratings were significantly higher when the sex and ethnicity of the patient were concordant with the provider (P=.021). This study showed that independent, nonmodifiable factors such as age, education level, and survey mode were significantly associated with the satisfaction of ambulatory spine surgery clinic patients. [Orthopedics. 2019; 42(3):143-148.].

Alcoholism as a predictor for pseudarthrosis in primary spine fusion: An analysis of risk factors and 30-day outcomes for 52,402 patients from 2005 to 2013.

INTRODUCTION: This study assessed the incidence and risk factors for pseudarthrosis among primary spine fusion patients. METHODS: Retrospective review of ACS-NSQIP (2005-2013). Differences in comorbidities between spine fusion patients with and without pseudarthrosis (Pseud, N-Pseud) were assessed using chi-squared tests and Independent Samples t-tests. Binary logistic regression assessed patient-related and procedure-related predictors for pseudarthrosis. RESULTS: 52,402 patients (57yrs, 53%F, 0.4% w/pseudarthrosis). Alcohol consumption (OR:2.6[1.2-5.7]) and prior history of surgical revision (OR:1.6[1.4-1.8]) were risk factors for pseudarthrosis operation. Pseud patients at higher risk for deep incisional SSI (at 30-days:OR:6.6[2.0-21.8]). Pseud patients had more perioperative complications (avg:0.24 ±â€¯0.43v0.18 ±â€¯0.39,p=0.026). CONCLUSIONS: Alcoholism and surgical revision are major risk factors for pseudarthrosis in patients undergoing spine fusion.

The Impact of Different Intraoperative Fluid Administration Strategies on Postoperative Extubation Following Multilevel Thoracic and Lumbar Spine Surgery: A Propensity Score Matched Analysis.

BACKGROUND: Patients undergoing multilevel spine surgery are at risk for delayed extubation. OBJECTIVE: To evaluate the impact of type and volume of intraoperative fluids administered during multilevel thoracic and/or lumbar spine surgery on postoperative extubation status. METHODS: Retrospective evaluation of medical records of patients ≥ 18 yr undergoing ≥ 4 levels of thoracic and/or lumbar spine fusions was performed. Patients were organized according to postoperative extubation status: immediate (IMEX; in OR/PACU) or delayed (DEX; outside OR/PACU). Propensity score matched (PSM) analysis was performed to compare IMEX and DEX groups. Volume, proportion, and ratios of intraoperative fluids administered were evaluated for the associated impact on extubation status. RESULTS: A total of 246 patients (198 IMEX, 48 DEX) were included. PSM analysis demonstrated that increased administration of non-cell saver blood products (NCSB) and increased ratio of crystalloid: colloids infused were independently associated with delayed extubation. With increasing EBL, IMEX had a proportionate reduction in crystalloid infusion (R = -0.5, P < .001), while the proportion of crystalloids infused remained relatively unchanged for DEX (R = -0.27; P = .06). Twenty-six percent of patients receiving crystalloid: colloid ratio > 3:1 had DEX compared to none of those receiving crystalloid: colloid ratio ≤ 3:1 (P = .009). DEX had greater cardiac and pulmonary complications, surgical site infections and prolonged intensive care unit and hospital stay (P < .05). CONCLUSION: PSM analysis of patients undergoing multilevel thoracic and/or lumbar spine fusion demonstrated that increased administration of crystalloid to colloid ratio is independently associated with delayed extubation. With increasing EBL, a proportionate reduction of crystalloids facilitates early extubation.

Lack of Cost Savings for Lumbar Spine Fusions After Bundled Payments for Care Improvement Initiative: A Consequence of Increased Case Complexity.

STUDY DESIGN: Retrospective analysis of Medicare claims and procedure details from a single institution participation in the Bundled Payments for Care Improvement (BPCI) program. OBJECTIVE: To analyze the effects of the BPCI program on patient outcome metrics and cost data. SUMMARY OF BACKGROUND DATA: The BPCI program was designed to improve the value of care provided to patients, but the financial consequences of this system remain largely unknown. We present 2 years of data from participation in the lumbar spine fusion bundle at a large, urban, academic institution. METHODS: In 2013 and 2014, all Medicare patients undergoing lumbar spine fusions for DGR 459 (spinal fusion except cervical with major complication or comorbidity [MCC]) and 460 (without MCC) at our institution were enrolled in the BPCI program. We compared the BPCI cohort to a baseline cohort of patients under the same diagnosis related groups (DRGs) from 2009 to 2012 from which the target price was established. RESULTS: Three hundred fifty patients were enrolled into the BPCI program, while the baseline group contained 518 patients. When compared with the baseline cohort, length of stay decreased (4.58 ±â€Š2.51 vs. 5.13 ±â€Š3.75; P = 0.009), readmission rate was unchanged, and discharges with home health aid increased. Nonetheless, we were unable to effect an episode-based cost savings ($52,655 ±â€Š27,028 vs. $48,913 ±â€Š24,764). In the larger DRG 460 group, total payments increased in the BPCI group ($51,105 ±â€Š26,347 vs. $45,934 ±â€Š19,638, P = 0.001). Operative data demonstrated a more complex patient mix in the BPCI cohort. The use of interbody fusions increased from 2% to 16% (P < 0.001), and the percentage of complex spines increased from 23% to 45% (P < 0.001). CONCLUSION: Increased case complexity was responsible for increasing costs relative to the negotiated baseline target price. This payment system may discourage advancement in spine surgery due to the financial penalty associated with novel techniques and technologies. LEVEL OF EVIDENCE: 3.

Preoperative Assessment of Bone Quality in Spine Deformity Surgery: Correlation With Clinical Practice and Published Recommendations.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The goals of this study were to (A) evaluate preoperative bone quality assessment and intervention practice over time and (B) review the current evidence for bone evaluation in spine fusion surgery. SUMMARY OF BACKGROUND DATA: Deformity spine surgery has demonstrated improved quality of life in patients; however, its cost has made it controversial. If preoperative bone quality can be optimized then potentially these treatments could be more durable; however, at present, no clinical practice guidelines have been published by professional spine surgical organizations. METHODS: A retrospective cohort review was performed on patients who underwent a minimum five-level primary or revision fusion. Preoperative bone quality metrics were evaluated over time from 2012 to 2017 to find potential trends. Subgroup analysis was conducted based on age, sex, preoperative diagnosis, and spine fusion region. RESULTS: Patient characteristics including preoperative rates of pseudarthrosis and junctional failure did not change. An increasing trend of physician bone health documentation was noted (P = 0.045) but changes in other metrics were not significant. A sex bias favored females who had higher rates of preoperative DXA studies (P = 0.001), Vitamin D 25-OH serum labs (P = 0.005), Vitamin D supplementation (P = 0.022), calcium supplementation (P < 0.001), antiresorptive therapy (P = 0.016), and surgeon clinical documentation of bone health (P = 0.008) compared with men. CONCLUSION: Our spine surgeons have increased documentation of bone health discussions but this has not affected bone quality interventions. A discrepancy exists favoring females over males in nearly all preoperative bone quality assessment metrics. Preoperative vitamin D level and BMD assessment should be considered in patients undergoing long fusion constructs; however, the data for bone anabolic and resorptive agents have less support. Clinical practice guidelines on preoperative bone quality assessment spine patients should be defined. LEVEL OF EVIDENCE: 4.

Early Lessons on Bundled Payment at an Academic Medical Center.

INTRODUCTION: Orthopaedic care is shifting to alternative payment models. We examined whether New York University Langone Medical Center achieved savings under the Centers for Medicare and Medicaid Services Bundled Payments for Care Improvement initiative. METHODS: This study was a difference-in-differences study of Medicare fee-for-service patients hospitalized from April 2011 to June 2012 and October 2013 to December 2014 for lower extremity joint arthroplasty, cardiac valve procedures, or spine surgery (intervention groups), or for congestive heart failure, major bowel procedures, medical peripheral vascular disorders, medical noninfectious orthopaedic care, or stroke (control group). We examined total episode costs and costs by service category. RESULTS: We included 2,940 intervention episodes and 1,474 control episodes. Relative to the trend in the control group, lower extremity joint arthroplasty episodes achieved the greatest savings: adjusted average episode cost during the intervention period decreased by $3,017 (95% confidence interval [CI], -$6,066 to $31). For cardiac procedures, the adjusted average episode cost decreased by $2,999 (95% CI, -$8,103 to $2,105), and for spinal fusion, it increased by $8,291 (95% CI, $2,879 to $13,703). Savings were driven predominantly by shifting postdischarge care from inpatient rehabilitation facilities to home. Spinal fusion index admission costs increased because of changes in surgical technique. DISCUSSION: Under bundled payment, New York University Langone Medical Center decreased total episode costs in patients undergoing lower extremity joint arthroplasty. For patients undergoing cardiac valve procedures, evidence of savings was not as strong, and for patients undergoing spinal fusion, total episode costs increased. For all three conditions, the proportion of patients referred to inpatient rehabilitation facilities upon discharge decreased. These changes were not associated with an increase in index hospital length of stay or readmission rate. CONCLUSION: Opportunities for savings under bundled payment may be greater for lower extremity joint arthroplasty than for other conditions.

Cervical spondylotic myelopathy: National trends in the treatment and peri-operative outcomes over 10years.

BACKGROUND: Recent studies show increases in cervical spine surgery prevalence and cervical spondylotic myelopathy (CSM) diagnoses in the US. However, few studies have examined outcomes for CSM surgical management, particularly on a nationwide scale. OBJECTIVE: Evaluate national trends from 2001 to 2010 for CSM patient surgical approach, postoperative outcomes, and hospital characteristics. METHODS: A retrospective nationwide database analysis provided by the Nationwide Inpatient Sample (NIS) including CSM patients aged 25+ who underwent anterior and/or posterior cervical fusion or laminoplasty from 2001 to 2010. Patients with fractures, 9+ levels fused, or any cancer were excluded. Measures included demographics, hospital data, and procedure-related complications. Yearly trends were analyzed using linear regression modeling. RESULTS: 54,348 discharge cases were identified. ACDF, posterior only, and combined anterior/posterior approach volumes significantly increased from 2001 to 2010 (98.62%, 303.07%, and 576.19%; respectively, p<0.05). However, laminoplasty volume remained unchanged (p>0.05). Total charges for ACDF, posterior only, combined anterior/posterior, and laminoplasty approaches all significantly increased (138.72%, 176.74%, 182.48%, and 144.85%, respectively; p<0.05). For all procedures, overall mortality significantly decreased by 45.34% (p=0.001) and overall morbidity increased by 33.82% (p=0.0002). For all procedures except ACDF, which saw a significantly decrease by 8.75% (p<0.0001), length of hospital stay was unchanged. CONCLUSIONS: For CSM patients between 2001 and 2010, combined surgical approach increased sixfold, posterior only approach increased threefold, and ACDF doubled; laminoplasties without fusion volume remained the same. Mortality decreased whereas morbidity and total charges increased. Length of stay decreased only for ACDF approach. This study provides clinically useful data to direct future research, improving patient outcomes.

The Effect of Smoking on Spinal Fusion.

BACKGROUND: Spinal fusion surgery is performed about half a million times per year in the United States and millions more worldwide. It is an effective method for reducing pain, increasing stability, and correcting deformity in patients with various spinal conditions. In addition to being a well-established risk factor for a variety of medical conditions, smoking has deleterious effects on the bone healing of spinal fusions. This review aims to specifically analyze the ways in which smoking affects the outcomes of spinal fusion and to explore ways in which these negative consequences can be avoided. PURPOSE: This article provides a complete understanding of the ways smoking affects spinal fusion from a biochemical and clinical perspective. Recommendations are also provided for ways in which surgeons can limit patient exposure to the most serious negative outcomes associated with cigarette smoking. STUDY DESIGN/SETTING: This study was a retrospective literature review done using the NCBI database. The research was compiled at NYU Hospital for Joint Diseases and the NYU Center for Musculoskeletal Care. METHODS: A comprehensive literature review was done spanning research on a variety of subjects related to smoking and spinal fusion surgery. The biochemistry of smoking and fusion healing were examined in great detail. In addition, both in vivo animal studies and human clinical studies were evaluated to explore fusion success related to the effects of smoking and its biochemical factors on spinal fusion surgery. RESULTS: Smoking significantly increases the risk of pseudoarthrosis for patients undergoing both lumbar and cervical fusions. In addition to nonunion, smoking also increases the risk of other perioperative complications such as infection, adjacent-segment pathology, and dysphagia. Treatment options are available that can be explored to reduce the risk of smoking-related morbidity, such as nicotine replacement therapy and use of bone morphogenetic proteins (BMPs). CONCLUSIONS: It has been clearly demonstrated from both a biochemical and clinical perspective that smoking increases the rate of perioperative complications for patients undergoing spinal fusion surgery, particularly pseudoarthosis. It has also been shown that there are certain approaches that can reduce the risk of morbidity. The most important recommendation is smoking cessation for four weeks after surgery. In addition, patients may be treated with certain surgical techniques, including the use of BMPs, to reduce the risk of pseudoarthrosis. Lastly, nicotine replacement therapy is an area of continued interest in relation to spinal fusion outcomes and more research needs to be done to determine its efficacy moving forward.

The use of the Risk Assessment and Prediction Tool in surgical patients in a bundled payment program.

OBJECTIVES: The purpose of this study was to evaluate the relationship between the Risk Assessment and Predictor Tool (RAPT) and patient discharge disposition in an institution participating in bundled payment program for total joint replacement, spine fusion and cardiac valve surgery patients. METHOD: Between April 2014 and April 2015, RAPT scores of 767 patients (535 primary unilateral total joint arthroplasty; 150 cardiac valve replacement; 82 spinal fusions) were prospectively captured. Total RAPT scores were grouped into three levels for risk of complications: <6 = 'high risk', between 6 and 9 = 'medium risk', and >9 = 'low risk' for discharge to a post-acute facility. Associations between RAPT categories and patient discharge to home versus any facility were conducted. Multivariate analysis was performed to determine if there was any correlation between RAPT score and discharge to any facility. RESULTS: 70.5% of total joint patients, 80.7% of cardiac valve surgery patients and 70.7% of spine surgery patients were discharged home rather than to a post-acute facility. RAPT risk categories were related to discharge disposition as 72% of those in the high risk group were discharged to a facility and 91% in the low risk group were discharged to home in the total joint replacement cohort. In the cardiac cohort, only 33% of the high risk group was discharged to a facility, and 94% of the low risk group was discharged to home. In the spinal fusion cohort, 60% of those in the high risk group were discharged to a facility and 86% in the low risk group were discharged to home. Multivariate analysis showed that being in the high risk category versus low risk category was significantly associated with substantially increased odds of discharge to a facility. CONCLUSION: The RAPT tool has shown the ability to predict discharge disposition for total joint and spine surgery patients, but not cardiac valve surgery patients, where the majority of patients in all categories were discharged home, at an institution participating in a bundled payment program. The ability to identify discharge disposition pre-operatively is valuable for improving care coordination, directing care resources and establishing and maintaining patient and family expectations.