Timing of Surgery for Thoracolumbar Spine Trauma: Patients With Neurological Injury.

STUDY DESIGN: Large multicenter retrospective cohort study. OBJECTIVE: The objective of this study was to analyze the effect of fusion timing on inpatient outcomes in a nationally representative population with thoracolumbar fracture and concurrent neurological injury. SUMMARY OF BACKGROUND DATA: Among thoracolumbar trauma admissions, concurrent neurological injury is associated with greater long-term morbidity. There is little consensus on optimal surgical timing for these patients; previous investigations fail to differentiate thoracolumbar fracture with and without neurological injury. MATERIALS AND METHODS: We analyzed 19,136 nonelective National Inpatient Sample cases (2004-2014) containing International Classifications of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes for closed thoracic/lumbar fracture with neurological injury and procedure codes for primary thoracolumbar/lumbosacral fusion, excluding open/cervical fracture. Timing classification from admission to fusion was same-day, 1-2-, 3-6-, and ≥7-day delay. Primary outcomes included in-hospital mortality, complications, and infection; secondary outcomes included total and postoperative length of stay and charges. Logistic regressions and generalized linear models with gamma distribution and log-link evaluated the effect of surgical timing on primary and secondary outcomes, respectively, controlling for age, sex, fracture location, fusion approach, multiorgan system injury severity score, and medical comorbidities. RESULTS: Patients undergoing surgery ≤72 hours (n=12,845) had the lowest odds of in-hospital cardiac [odds ratio (OR)=0.595; 95% confidence interval (CI), 0.357-0.991] and respiratory complications (OR=0.495; 95% CI, 0.313-0.784) and infection (OR=0.615; 95% CI, 0.390-0.969). No differences were observed between same-day (n=4724) and 1-2-day delay (n=8121) (P>0.05). Lowest odds of hemorrhage or hematoma was observed following 3-6-day delay (OR=0.467; 95% CI, 0.236-0.922). A ≥7-day delay to fusion (n=2,002) was associated with greatest odds of hemorrhage/hematoma (OR=2.019; 1.107-3.683), respiratory complications (OR=1.850; 95% CI, 1.076-3.180), and infection (OR=3.155; 95% CI, 1.891-5.263) and greatest increases in mean postoperative length of stay (4.26% or 35.3% additional days) and charges (163,562 or 71.7% additional US dollars) (P<0.001). CONCLUSIONS: Patients with thoracolumbar fracture and associated neurological injury who underwent surgery within 3 days of admission experienced fewer in-hospital complications. These benefits may be due to secondary injury mechanism avoidance and earlier mobilization. LEVEL OF EVIDENCE: Level III.

Critical Assessment of the Contemporary Orthopaedic Surgery Residency Application Process.

BACKGROUND: Matching into orthopaedic surgery residency in the United States has become an increasingly competitive process because of the large number of well-qualified applicants. Over the past several years, applicants have sought to maximize their chances of matching by submitting an increasing number of applications. The purpose of this study was to assess trends in application numbers, applicant qualifications, and application reviews, with the goal of obtaining data to help inform future improvements in the orthopaedic surgery residency application process. METHODS: Applicant data were obtained from the Electronic Residency Application Service (ERAS, www.aamc.org/services/eras/stats) and the National Resident Matching Program (NRMP, www.nrmp.org/report-archives). These included residency application data from 2000 to 2017. In addition, we analyzed available NRMP Applicant Survey Reports between 2008 and 2017, Program Director Survey Reports between 2008 and 2016, and NRMP's Charting Outcomes in the Match between 2006 and 2016. RESULTS: The number of U.S. senior medical student applicants per orthopaedic surgery residency position was stable from 2000 to 2017 (1.13 vs. 1.16 for 2000 and 2017, respectively). A significant increase in the United States Medical Licensing Examination (USMLE) Step-1 and Step-2 scores and self-reported research activity was present over the same time period. The number of applications submitted per applicant significantly increased, by 71.7%, from 48.4 in 2006 to 83.1 in 2017. Additionally, applications per program increased 46.4% from 457 in 2010 to 669 in 2016. In 2010, programs performed in-depth reviews for 54% of applications; however, in 2016, in-depth reviews had decreased to 45% of applications. CONCLUSIONS: Orthopaedic residency applicant USMLE scores and research productivity have increased over time. Concurrently, the average number of applications submitted per applicant has increased, with the average applicant applying to nearly half of all orthopaedic residency programs. Consequently, programs have seen more than double the number of applications over this study period. The accompanying decline in the proportion of applications undergoing in-depth review, along with the applicant and program resources associated with these changes, warrants the development of strategies to enhance the efficiency of the application process for orthopaedic residency.

Proximal junctional failure prevention in adult spinal deformity surgery utilizing interlaminar fixation constructs.

Proximal junctional kyphosis (PJK) is a common complication following fusion for Adult Spinal Deformity. PJK and proximal junctional failure (PJF) may lead to pain, neurological injury, reoperation, and increased healthcare costs. Efforts to prevent PJK and PJF have aimed to preserve or reconstruct the posterior spinal tension band and/or modifying instrumentation to allow for more gradual transitions in stiffness at the cranial end of long spinal constructs. We describe placement of an interlaminar fixation construct at the upper instrumented vertebra which may decrease PJK/PJF severity, and is placed with little additional operative time and minimal posterior soft tissue trauma.

Longer Operative Time in Elderly Patients Undergoing Posterior Lumbar Fusion Is Independently Associated With Increased Complication Rate.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine the effects of operative time on postoperative complications in patients age 65 and older undergoing posterior lumbar fusion. METHODS: All patients age 65 and older undergoing posterior lumbar fusion were identified in the 2012 to 2015 American College of Surgeons National Surgical Quality Improvement Program database. The primary outcome measures were complications occurring up to 30 days postoperatively, including death, any complication, and complication subtypes. The primary independent variable was operative duration. Both bivariate and multivariate analyses utilized logistic regression and analyzed operative duration as a continuous variable. Statistical significance was considered P < .05. RESULTS: A total of 4947 patients age 65 and older undergoing posterior lumbar fusion were identified. The mean operative time was 3.3 hours (SD 1.7). The overall complication rate was 13.4% (n = 665). In multivariate analysis, each incremental hour of operative time was associated with increased risk of postoperative thromboembolism (odds ratio [OR] = 1.23; 95% confidence interval [CI] = 1.10-1.37), transfusion (OR= 1.25; 95% CI = 1.18-1.32), urinary tract infection (OR = 1.21; 95% CI = 1.10-1.32), and total postoperative complications (OR = 1.22; 95% CI = 1.16-1.27). CONCLUSION: For patients age 65 and older undergoing posterior lumbar fusion, longer operative time is associated with greater risk for thromboembolism, transfusion, intubation, kidney injury, urinary tract infection, surgical site infection, and overall postoperative complications. This data highlights several specific complications that are influenced by operative time in older patients, and further supports the need for future protocols that seek to safely minimize operative time for posterior lumbar fusion.

Sex- and Sport-Specific Epidemiology of Cervical Spine Injuries Sustained During Sporting Activities.

BACKGROUND: Although several investigations have examined the epidemiology of cervical spine injuries in sports, few studies have analyzed the nationwide incidence and sex-specific epidemiology of cervical spine injuries. METHOD: The National Electronic Injury Surveillance System database, which collects information on patients presenting to the emergency department at 100 hospitals across the United States, was queried for neck sprains and cervical fractures associated with sporting activities from 2000-2015. RESULT: A total of 26,380 neck sprains and 1166 fractures were identified. Compared with females, the incidence for injuries in males was 1.7 times greater for neck sprains and 3.6 times greater for fractures (P < 0.0001). Football was the most common cause of cervical sprains in males, followed by cycling and weightlifting/aerobics. Females sustained most neck sprains in weightlifting/aerobics, trampoline, and cheerleading. From 2000 to 2015, the incidence of neck sprains from aerobics increased from 15.5 to 25.3 per million person-years (P < 0.0001). Similarly, the incidence of cervical fractures from cycling increased from 0.67 to 2.7 per million (P < 0.0001). For males, cycling was the most common cause of fracture, followed by diving/swimming and football. For females, horseback riding was most common, followed by cycling and diving/swimming. CONCLUSIONS: Football is the leading cause of cervical sprains in the United States. The most common cause of cervical fracture in men is cycling, while in women it is horseback riding. The incidence of sport-related cervical fractures has increased by 35% from 2000 to 2015, which has been driven by an increase in cycling-related injuries.

Tobacco Use and Complications Following Spinal Fusion: A Comparison of the National Surgical Quality Improvement Program and National Inpatient Sample Datasets.

BACKGROUND: Smoking is a known risk factor for inferior health outcomes. Retrospective analyses of large datasets may assess whether such risk is manifested or mitigated in clinical practice. Although many risk factor analyses use the National Surgical Quality Improvement Program (NSQIP) and National (Nationwide) Inpatient Sample (NIS), such investigations have seldom been directly compared. METHODS: NIS and NSQIP datasets were used. Primary outcome measures were perioperative complications. NSQIP complications were stratified based on occurrence before versus after discharge. Multiple logistic regression was employed in adjusted analyses. RESULTS: Among NSQIP (N = 56,145) and NIS (N = 1,311,426) patients, 24.0% and 31.8% were identified as tobacco users, respectively. Before discharge, NSQIP smokers had increased odds of pneumonia (adjusted odds ratio [aOR] = 1.43), postoperative intubation (aOR = 1.40), and sepsis (aOR = 1.71) and decreased odds of pulmonary embolism (aOR = 0.57) (all P < 0.05). After discharge, NSQIP smokers exhibited increased odds of cardiac arrest (aOR = 2.53) and surgical site infection (aOR = 1.25) and decreased odds of urinary tract infection (aOR = 0.68) and deep venous thrombosis (aOR = 0.61) (all P < 0.05). In adjusted analysis of NIS data, tobacco users exhibited increased odds of inpatient pneumonia (aOR = 1.57), myocardial infarction (aOR = 1.29), and postoperative intubation (aOR = 1.15) and decreased odds of pulmonary embolism (aOR = 0.80) and deep venous thrombosis (aOR = 0.78) (all P < 0.05). CONCLUSIONS: Patients with a history of tobacco use undergoing spinal fusion were at increased risk of pneumonia and intubation but decreased risk of deep venous thrombosis and pulmonary embolism during the inpatient postoperative stay. After discharge, smokers exhibited increased odds of cardiac arrest and surgical site infection. NIS and NSQIP results were similar, with 9 of 12 outcomes exhibiting identical inpatient conclusions. Qualitative comparison of NIS and NSQIP yields results that offer increased validity over single-source studies.

Early Subspecialization in Orthopedic Surgery Training.

Recent studies have shown that applicants to the American Board of Orthopaedic Surgery Part II examination are performing fewer procedures outside of their chosen subspecialty. In this study, the authors assessed whether trainees are beginning their subspecialization during residency. The authors reviewed the chosen fellowships and case logs of 231 residents graduating from 5 academic orthopedic residency training programs from 2002 to 2017. The number of cases logged by residents who chose a specialty was then compared with the number of cases logged by residents who chose other specialties. Residents who chose spine surgery (108.4±50.7 vs 74.4±60.2, P<.01), hand surgery (242.2±92.9 vs 194.3±78.2, P<.01), and sports medicine (278.5±105.8 vs 229.0±93.9, P<.01) performed significantly more procedures in their chosen fields than their colleagues. In contrast, for total joint arthroplasty (P=.18) and foot and ankle surgery (P=.46), there was no significant difference in the number of cases between residents who chose the sub-specialty and those who did not. Residents pursuing careers in spine surgery, hand surgery, and sports medicine obtained additional operative exposure to their chosen field during residency. Formalizing this early experience with specialization tracks during the chief year may be considered. [Orthopedics. 2019; 42(1):e39-e43.].

Predictive factors of positive online patient ratings of spine surgeons.

BACKGROUND: Online physician rating websites are increasingly used by patients to evaluate their doctors. The purpose of this investigation was to evaluate factors associated with better spine surgeon ratings. METHODS: Orthopedic spine surgeons were randomly selected from the North American Spine Society directory utilizing a random number generator. Surgeon profiles on three physician rating websites, namely, www.HealthGrades.com, www.Vitals.com, and www.RateMDs.com, were analyzed to gather qualitative and quantitative data on patients' perceptions of the surgeons. Independent variables from the websites were analyzed in relation to overall physician or patient satisfaction rating. Comments were coded by subject into following three categories: professional competence, bedside manner, and practice characteristics. RESULTS: A total of 250 surgeons were evaluated, and 92% (n=230) of these doctors had at least one rating among the three websites. The surgeons with a higher average rating had significantly better trust (p<.01), scheduling (p<.01), staff (p<.01), helpfulness (p<.01), and punctuality (p<.01) scores but significantly less experience (p<.05). A linear regression model for the average rating of each surgeon (R2 value=0.754) yielded only following three significant variables: trustworthiness (p<.01), experience match (p<.05), and the average number of negative comments on surgeon's professional competence (p<.05). Trustworthiness (ß=0.749) was the strongest predictor variable of physician rating, followed by the number of negative professional competence comments (ß=-0.132) and experience match (ß=-0.112). CONCLUSIONS: This investigation assessed spine surgeon online patient ratings and categorized factors that patients associate with quality care. Trustworthiness was the most significant predictor of positive ratings, whereas ease of scheduling, quality of staff, helpfulness, and punctuality were also associated with higher patient ratings. Understanding what patients value may help optimize care of spine surgery patients.

Machine learning modeling for predicting hospital readmission following lumbar laminectomy.

In BriefAuthors of this study analyzed hospital readmissions following laminectomy and developed predictive models to identify readmitted patients with an accuracy >95% when using all variables and >79% when using only predischarge variables. A model capable of predicting 40% of readmitted patients was created using only the variables known predischarge. This investigation is important in its provision of data that will assist the development of predictive models for readmission as well as interventions to prevent readmission in high-risk patients.

Trends in the Orthopaedic Surgery Subspecialty Fellowship Match: Assessment of 2010 to 2017 Applicant and Program Data.

BACKGROUND: Orthopaedic surgery has become increasingly specialized, and most trainees currently complete subspecialty fellowship training. The purposes of this investigation were to evaluate recent trends in U.S. orthopaedic fellowship matches and to provide relevant analyses for future orthopaedic fellowship applicants and fellowship program directors. METHODS: This study analyzed data from orthopaedic fellowship match programs from 2010 to 2017. For each fellowship, the following variables were analyzed: numbers of positions offered, participating programs, applicant registrations, rank lists submitted by applicants (i.e., completed applications), applicants matched, and filled positions. Applicant-matching success rate and percentage of total fellowship positions filled for each subspecialty were calculated, and trends were evaluated for significance and difference between subspecialties utilizing ordinary least-square regressions, with p < 0.05 indicating significance. RESULTS: From 2010 to 2017, the number of fellowship positions that were offered increased in all subspecialties (p < 0.05) except for spine (p = 0.44) and trauma (p = 0.92). Participating fellowship programs increased in all subspecialties (p < 0.05) except spine (p = 0.38) and sports medicine; the latter experienced the only significant decrease (p < 0.05). The largest significant increases (p < 0.05) in both applicant registrations (33.5%) and rank lists submitted by applicants (45.3%) were in adult reconstruction. The subspecialty with the highest applicant-matching success rate during the study period of 2010 to 2017 was sports (mean, 93.5%). Spine and trauma had the lowest applicant-matching success rates in 2016 to 2017. The percentage of positions filled across all subspecialties increased from 2011 to 2017 (p < 0.05); hand had the highest mean (96.6% filled), and adult reconstruction had the largest significant increase from 82.0% in 2010 to 95.5% in 2017 (p < 0.05). CONCLUSIONS: This investigation provides data with regard to current trends in the orthopaedic fellowship match. Specifically, adult reconstruction fellowship training has recently gained popularity at a more rapid rate than the other subspecialty fellowship pathways, although hand surgery consistently maintains a very high rate of positions filled. Our results for orthopaedic subspecialty fellowship match trends may assist fellowship directors with program planning and career advising and may also assist current residents with fellowship application expectations and career planning.

Physician and patients factors associated with outcome of spinal epidural abscess related malpractice litigation.

Spinal epidural abscesses (SEA) can be challenging to diagnose and may result in serious adverse outcomes sometimes leading to neurologic compromise, sepsis, and even death. While SEA may lead to litigation for healthcare providers, little is known about the medicolegal factors predicting case outcome of SEA related litigation cases. Three large medicolegal databases (VerdictSearch, Westlaw, and LexisNexis) were queried for SEA-related malpractice cases. Plaintiff (patient) age, sex, previous infection history and clinical outcomes such as residual paraplegia/quadriplegia, and delay in diagnosis or treatment were examined. The relationship between these variables and the proportion of plaintiff rulings and size of indemnity payments were assessed. Of the 135 cases that met inclusion criteria, 29 (21.5%) settled, 59 (43.7%) resulted in a defendant ruling, and 47 (34.8%) resulted in a plaintiff ruling. Mean award for plaintiff rulings was $4,291,400 (95% CI, $5,860,129 to $2,722,671), which was significantly larger than mean awards for cases that settled out of court, $2,324,170 (95% CI, $3,206,124 to $1,442,217) (P<0.05). The proportion of plaintiff verdicts and size of monetary awards were not significantly related to age or sex of the patient. A previously known infection was not significantly associated with the proportion of plaintiff verdicts or indemnity payments (P>0.05). In contrast, plaintiff verdicts were more common for patients who became paraplegic or quadriplegic (P<0.02) and were associated with significantly higher monetary awards (P<0.05) relative to patients without paralysis. Plaintiff verdicts were also more common when cases had an associated delay in diagnosis (P=0.008) or delay in treatment (P<0.001). Internists were the most commonly sued physician named in 20 (14.8%) suits, followed by anesthesiologists in 13 (9.6%) suits, emergency medicine physicians in 12 (8.9%) suits, family medicine physicians in 9 (6.7%) suits, neurosurgeons and orthopedic surgeons in 6 (4.4%) suits each, and multiple providers in 2 (1.5%) suits. The remaining lawsuits were against a hospital or another specialty not previously listed This investigation examined legal claims associated with SEA and found that the likelihood of a plaintiff verdict was significantly related to patient outcome (paralysis) and physician factors (delay in diagnosis or treatment compared). Additionally, paralyzed plaintiffs receive higher award payouts. Non-operative physicians, who are often responsible for initial diagnosis, were more frequently named in malpractice suits than surgeons. Increased awareness of the medicolegal implications of SEA can better prevent delays in diagnosis and treatment, and thus, alleged negligence-based lawsuits.

Risk Factors for Unplanned Reoperation Within 30 Days Following Elective Posterior Lumbar Spinal Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Unplanned reoperation following lumbar spinal fusion is detrimental to patients, providers, and health systems. The aim of this study was to identify risk factors associated with unplanned reoperation following elective posterior lumbar spinal fusion and assess the reasons for reoperation. METHODS: A retrospective analysis of 22 151 patients from the American College of Surgeons National Surgical Quality Improvement Program data set between 2012 and 2015 was completed. The primary outcome measure was unplanned reoperation within 30 days. Secondary outcome measures were specific diagnoses and procedures associated with unplanned reoperation, as well as time to reoperation from initial procedure. Multiple stepwise logistic regression was employed to determine preoperative variables predictive of unplanned 30-day reoperation. RESULTS: Patients with disseminated cancer (OR = 3.44, P = .0049), weight loss >10% in 6 months prior to surgery (OR = 3.26, P = .0276), bleeding disorders (OR = 1.92, P = .0049), American Society of Anesthesiologists score of 3 (OR = 1.46, P < .0001), body mass index of 35.0 to 39.9 (OR = 1.50, P = .0037), body mass index of ≥40 (OR = 1.83, P < .0001), and multilevel fusion (OR = 1.24, P = .0069) exhibited increased odds of 30-day reoperation. The most common diagnosis associated with reoperation was postoperative infection (n = 121, 21.1% of reoperations). CONCLUSIONS: Predictors and causes of unplanned reoperation within 30 days following elective posterior lumbar spinal fusion are identifiable. In this study cohort, obesity, American Society of Anesthesiologists score, disseminated cancer, weight loss, bleeding disorders, and multilevel fusion were identified as significant risk factors for reoperation. Further research investigating risk factor modification on reoperation in elective posterior lumbar spinal fusion is warranted.

Predictors of Nonneurologic Complications and Increased Length of Stay After Cervical Spine Osteotomy.

BACKGROUND: Although previous studies have used National Surgical Quality Improvement Program (NSQIP) data to study complications of thoracolumbar spinal deformity surgery, investigation of cervical spine deformity surgery has been limited. We performed a retrospective analysis of the NSQIP database to identify predictors of complications after cervical spine osteotomy. METHODS: Patients undergoing cervical spine osteotomy were identified in the NSQIP dataset using Current Procedural Terminology codes from years 2007-2016. For each patient, patient and case clinical characteristics, length of stay (LOS), and diagnosis of a nonneurologic complication (including reoperation and readmission) were abstracted. Patient and case clinical predictors of any of the reported complications and increased LOS were identified in multivariate logistic and Poisson regression analyses, respectively. RESULTS: There were 950 patients identified with mean age 56.1 ± 12.4 years and mean body mass index 29.9 ± 6.8. Mean LOS was 3.5 ± 4.9 days. Overall medical complication rate was 15.8%. The most common complications were transfusion (78; 8.2%), readmission (45; 4.7%), reoperation (32; 3.4%), and reintubation (28; 3.0%). Risk factors for any complication included increased age (P = 0.0467), American Society of Anesthesiologists classification III (P = 0.0023) and IV (P = 0.0013), and increased operative duration (P < 0.0001). Risk factors for increased LOS were decreased functional status (P = 0.0037), disseminated cancer (P = 0.0061), American Society of Anesthesiologists classification III and IV (P < 0.0001), increased operative duration (P < 0.0001), and orthopaedic surgeon (vs. neurosurgeon) (P = 0.0156). CONCLUSIONS: This study is the largest to date of patients undergoing cervical osteotomy and provides useful clinical data for patient selection and counseling and 30-day reoperation and readmission rates.

Timing of complications following posterior cervical fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To characterize the timing of complications after posterior cervical fusion. SUMMARY OF BACKGROUND DATA: Understanding the expected timing of postoperative complications facilitates early diagnosis of potential adverse events and is important for optimizing postoperative care. Though studies have examined the incidence of complications after posterior cervical fusion, no study has characterized the timing of these complications. METHODS: Patient data in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) dataset with a primary CPT code 22600, corresponding to posterior cervical fusion, was analyzed for demographics, comorbidities, and ten specific complications. Complication timing was assessed, and univariate analysis was performed to investigate the relationship of patient demographic and clinical variables on the development of postoperative complications. RESULTS: A total of 2517 patients with a mean age of 59.3 ±â€¯12.5 met inclusion criteria. The overall complication rate was 12.4%. The median day of diagnosis and interquartile range for each complication was: blood transfusion (0.0, 0-0), myocardial infarction (3, 2-7), reintubation (3, 1-9), pneumonia (4, 3-10), deep venous thrombosis (7, 5-16), urinary tract infection (11.5, 5-17.5), sepsis (14, 7-20), pulmonary embolism (14, 8-21), surgical site infection (15, 9-21), and wound dehiscence (15.5, 9-25). Less than 50% deep venous thromboses were diagnosed before discharge, and less than 30% of pulmonary emboli were diagnosed before discharge. On univariate analysis, increased age, decreased functional status, fusing more than one level, current smoker status, diabetes, and CHF were associated with increased complications. CONCLUSIONS: This timing data is useful to the practicing spine surgeon as it provides a guide for when to expect and investigate for specific complications after posterior cervical procedures. It may aid in the early diagnosis of complications and may also assist in healthcare reimbursement negotiations.

Rod Fracture After Apparently Solid Radiographic Fusion in Adult Spinal Deformity Patients.

BACKGROUND: Rod fracture occurs with delayed fusion or pseudarthrosis after adult spinal deformity (ASD) surgery. Rod fracture after apparent radiographic fusion has not been previously investigated. METHODS: Patients with ASD in a multicenter database were assessed for radiographic fusion by a committee of 3 spinal deformity surgeons. Fusions were rated as bilaterally fused (A), unilaterally fused (B), partially fused (C), or not fused (D). Patients with grade A or B fusion and 2-year follow-up were included. Patients with radiographic fusion were evaluated for subsequent rod fracture. Adjusted analyses were conducted with multiple logistic regression, using backwards-variable selection to a threshold of P < 0.2, to assess for associated factors. RESULTS: Of 402 patients with radiographically apparent solid fusion, 9.5% (38) subsequently suffered a broken rod. On multivariate analysis, greater rates of rod fracture were seen among patients of age group 60-69 years (vs. 18-49), body mass index 30-34 and 35+ (vs. <25), stainless-steel rods (vs. titanium), patients with rods ≤5.5 mm (vs. 6.35 mm), and patients with Charlson score 0 (vs. 3+). Of the 38 patients with rod fractures, 18 (47.4%) presented with worsened pain, and 8 (21.1%) required revision at minimum 2-year follow-up. CONCLUSIONS: Rod fracture occurred in 9.5% of patients with apparently solid radiographic fusion after ASD surgery. Advanced age, obesity, small diameter rods (5.5 mm), osteotomy, and lower comorbidity burden were significantly associated with rod fracture. Nearly one-half of these patients noted worsening pain, and 21.1% required revision surgery. Instrumentation failure may occur and may be symptomatic even in the setting of apparent fusion on plain radiographs.

Ileus Following Adult Spinal Deformity Surgery.

BACKGROUND: Postoperative ileus (POI) is a common complication after spine surgery, with particularly high rates after adult spinal deformity (ASD) surgery. Few studies have been conducted on predictors of POI following ASD surgery. The objective of this study was to determine risk factors for POI in patients undergoing ASD surgery and to determine association between POI and in-hospital mortality, length of stay, and total charges. METHODS: Data were obtained from the National (Nationwide) Inpatient Sample, years 2010-2014. Patients with ASD ≥26 years-old were selected using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Multiple logistic and linear regressions were used. RESULTS: The analysis included 59,410 patients; 7.4% of patients had POI. On adjusted analysis, the following variables were associated with increased risk of POI: male sex (OR = 1.43; CI, 1.10-1.85), anterior surgical approach (OR = 1.78; CI, 1.22-2.60), ≥9 levels fused (OR = 1.84; CI, 1.24-2.73), electrolyte disorders (OR = 2.70; CI, 2.15-3.39), and pathologic weight loss (OR = 1.94; CI, 1.08-3.46). POI was associated with significantly longer length of stay (+39% [CI, 29%-51%]) and higher total charges (+23% [CI, 14%-31%]). CONCLUSIONS: Risk factors for POI were identified. Length of stay was 2.9 days longer in patients with POI, and total charges were approximately $80,000 higher. These results may be applied clinically to identify patients at risk of POI and to address modifiable risk factors preoperatively. Future studies should be conducted with additional data to develop models capable of accurately predicting and preventing POI.

Late-presenting dural tear: incidence, risk factors, and associated complications.

BACKGROUND CONTEXT: Unrecognized and inadequately repaired intraoperative durotomies may lead to cerebrospinal fluid leak, pseudomeningocele, and other complications. Few studies have investigated durotomy that is unrecognized intraoperatively and requires additional postoperative management (hereafter, late-presenting dural tear [LPDT]), although estimates of LPDT range from 0.6 to 8.3 per 1,000 spinal surgeries. These single-center studies are based on relatively small sample sizes for an event of this rarity, all with <10 patients experiencing LPDT. PURPOSE: This investigation is the largest yet conducted on LPDT, and sought to identify incidence, risk factors for, and complications associated with LPDT. STUDY DESIGN/SETTING: This observational cohort study employed the American College of Surgeons National Surgical Quality Improvement Program dataset (years 2012-2015). PATIENT SAMPLE: Patients who underwent spine surgery were identified based on presence of primary listed Current Procedural Terminology (CPT) codes corresponding to spinal fusion or isolated posterior decompression without fusion. OUTCOME MEASURES: The primary variable in this study was occurrence of LPDT, identified as reoperation or readmission with durotomy-specific CPT or International Classification of Diseases, Ninth Revision, Clinical Modification codes but without durotomy codes present for the index procedure. METHODS: Descriptive statistics were generated. Bivariate and multivariate analyses were conducted using chi-square tests and multiple logistic regression, respectively, generating both risk factors for LPDT and independent association of LPDT with postoperative complications. Statistical significance was defined as p<.05. RESULTS: In total, 86,212 patients were analyzed. The overall rate of reoperation or readmission without reoperation for LPDT was 2.0 per 1,000 patients (n=174). Of LPDT patients, 97.7% required one or more unplanned reoperations (n=170), and 5.7% of patients (n=10) required two reoperations. On multivariate analysis, lumbar procedures (odds ratio [OR] 2.79, p<.0001, vs. cervical), procedures involving both cervical and lumbar levels (OR 3.78, p=.0338, vs. cervical only), procedures with decompression only (OR 1.72, p=.0017, vs. fusion and decompression), and operative duration ≥250 minutes (OR 1.70, p=.0058, vs. <250 minutes) were associated with increased likelihood of LPDT. Late-presenting dural tear was significantly associated with surgical site infection (SSI) (OR 2.54, p<.0001), wound disruption (OR 2.24, p<.0001), sepsis (OR 2.19, p<.0001), thromboembolism (OR 1.71, p<.0001), acute kidney injury (OR 1.59, p=.0281), pneumonia (OR 1.14, p=.0269), and urinary tract infection (UTI) (OR 1.08, p=.0057). CONCLUSIONS: Late-presenting dural tears occurred in 2.0 per 1,000 patients who underwent spine surgery. Patients who underwent lumbar procedures, decompression procedures, and procedures with operative duration ≥250 minutes were at increased risk for LPDT. Further, LPDT was independently associated with increased likelihood of SSI, sepsis, pneumonia, UTI, wound dehiscence, thromboembolism, and acute kidney injury. As LPDT is associated with markedly increased morbidity and potential liability risk, spine surgeons should be aware of best-practice management for LPDT and consider it a rare, but possible etiology for developing postoperative complications.

Diagnostic Criteria and Clinical Outcomes in Sarcopenia Research: A Literature Review.

By the sixth decade of life, nearly one quarter of the population has substantial muscle atrophy, or sarcopenia. Despite the creation of a standardized definition of sarcopenia by the European Working Group on Sarcopenia in Older People, variability may exist in the diagnostic criteria utilized for clinical sarcopenia research. The primary objectives of this review were to characterize diagnostic criteria used for measurement of sarcopenia in original studies, and to describe associations between sarcopenia and important clinical outcomes. We performed a literature review of the term "sarcopenia" in PubMed. Inclusion criteria were English language, original data, a clear and specific definition for diagnosing sarcopenia, and the analysis of sarcopenia's effect on a clinical outcome. A total of 283 studies met inclusion criteria. More than half of the included sarcopenia investigations were level IV studies (54.1%), while 43.1% provided level II evidence. Under one third (27.6%) of studies examined sarcopenia with regard to surgical outcomes. In terms of diagnostic criteria for sarcopenia, 264 (93.3%) studies used measures of skeletal muscle mass, with dual energy X-ray absorptiometry (DEXA) being the most common modality (43.6%). Sarcopenia was found to be a consistent predictor of chronic disease progression, all-cause mortality, poorer functional outcomes, and postoperative complications. In conclusion, there is substantial evidence that sarcopenia impacts both medical and surgical outcomes. However, current research has utilized heterogeneous diagnostic criteria for sarcopenia. Further efforts to standardize the modalities used to diagnose sarcopenia in clinical research and practice will help strengthen our ability to study this important phenomenon.

Variability in Treatment for Patients with Cervical Spine Fracture and Dislocation: An Analysis of 107,152 Patients.

BACKGROUND: Cervical spine injuries are a common cause of morbidity and mortality; however, the optimal treatment of many of these injuries is debated, and previous studies have shown substantial variation in treatment. We sought to examined treatment variation in arthrodesis and halo/tong placement in cervical spine injury patients over a 12-year period. METHODS: Data from the Healthcare Cost and Utilization Project National Inpatient Sample, from 2000 to 2011, were used for this study. Patients were identified with a cervical vertebral facture or dislocation based on the International Classification of Diseases, 9th Revision codes. Using χ2 analysis, spinal arthrodesis rates and halo/tong placement rates were compared between hospitals based on teaching status for patients with and without spinal cord injury (SCI). RESULTS: The records of 107,152 patients with cervical fractures were examined. From 2000 to 2011, the overall arthrodesis rates fell from 25.2% to 20.6% (P < 0.001), and halo/tong placement rates fell from 13.2% to 3.6% (P < 0.001). In patients with cervical fracture without SCI, arthrodesis rates fell from 17.6% to 13.9% (P < 0.001), in cervical fracture patients with SCI, arthrodesis rates rose from 50.0% to 58.9% (P < 0.001), and in cervical dislocation patients, arthrodesis rates rose from 47.6% to 57.5% (P < 0.001). During the 12-year period, teaching hospitals had higher arthrodesis rates compared with nonteaching hospitals for patients with cervical fractures with SCI (57.3% vs. 53.4%, P = 0.001) and higher halo/tong placement rates for patients with cervical dislocations (2.7% vs. 1.7%, P = 0.004). Individual hospital variation showed a 3.5-fold variation in arthrodesis rates in 2000 to 2002, which fell to 3.0-fold by 2009 to 2011. CONCLUSIONS: Arthrodesis rates for cervical fracture patients significantly decreased, and arthrodesis rates for cervical dislocation and SCI patients increased from 2000 to 2011, with variability in treatment based on hospital teaching status. Rates of halo/tong placement rapidly decreased for cervical spine trauma at both teaching and nonteaching hospitals. Individual hospital treatment variation also decreased over the study period. Further clinical studies examining the optimal treatment for spine trauma may lead to continued decreases in treatment variability.

Radiation Exposure and Health Risks for Orthopaedic Surgeons.

Orthopaedic surgeons are routinely exposed to intraoperative radiation and, therefore, follow the principle of "as low as reasonably achievable" with regard to occupational safety. However, standardized education on the long-term health effects of radiation and the basis for current radiation exposure limits is limited in the field of orthopaedics. Much of orthopaedic surgeons' understanding of radiation exposure limits is extrapolated from studies of survivors of the atomic bombings in Hiroshima and Nagasaki, Japan. Epidemiologic studies on cancer risk in surgeons and interventional proceduralists and dosimetry studies on true radiation exposure during trauma and spine surgery recently have been conducted. Orthopaedic surgeons should understand the basics and basis of radiation exposure limits, be familiar with the current literature on the incidence of solid tumors and cataracts in orthopaedic surgeons, and understand the evidence behind current intraoperative fluoroscopy safety recommendations.