Who Can Be Discharged Home after Adult Spinal Deformity Surgery?

Introduction: After adult spinal deformity (ASD) surgery, patients often require postoperative rehabilitation at an inpatient rehabilitation (IPR) center or a skilled nursing facility (SNF). However, home discharge is often preferred by patients and hsas been shown to decrease costs. In a cohort of patients undergoing ASD surgery, we sought to (1) report the incidence of discharge to home, (2) determine the factors significantly associated with discharge to home in the form of a simple scoring system, and (3) evaluate the impact of discharge disposition on patient-reported outcome measures (PROMs). Methods: A single-institution, retrospective cohort study was undertaken for patients undergoing ASD surgery from 2009 to 2021. Inclusion criteria were ≥ 5-level fusion, sagittal/coronal deformity, and at least 2-year follow-up. Exposure variables included preoperative, perioperative, and radiographic data. The primary outcome was discharge status (dichotomized as home vs. IPR/SNF). Secondary outcomes included PROMs, such as the numeric rating scales (NRSs) for back and leg pain, the Oswestry Disability Index (ODI), and EQ-5D. A subanalysis comparing IPR to SNF discharge was conducted. Univariate analysis was performed. Results: Of 221 patients undergoing ASD surgery with a mean age of 63.6 ± 17.6, 112 (50.6%) were discharged home, 71 (32.2%) were discharged to an IPR center, and 38 (17.2%) were discharged to an SNF. Patients discharged home were significantly younger (55.7 ± 20.1 vs. 71.8 ± 9.1, p < 0.001), had lower rate of 2+ comorbidities (38.4% vs. 45.0%, p = 0.001), and had less hypertension (57.1% vs. 75.2%, p = 0.005). Perioperatively, patients who were discharged home had significantly fewer levels instrumented (10.0 ± 3.0 vs. 11.0 ± 3.4 levels, p = 0.030), shorter operative times (381.4 ± 139.9 vs. 461.6 ± 149.8 mins, p < 0.001), less blood loss (1101.0 ± 977.8 vs. 1739.7 ± 1332.9 mL, p < 0.001), and shorter length of stay (5.4 ± 2.8 vs. 9.3 ± 13.9 days, p < 0.001). Radiographically, preoperative SVA (9.1 ± 6.5 vs. 5.2 ± 6.8 cm, p < 0.001), PT (27.5 ± 11.1° vs. 23.4 ± 10.8°, p = 0.031), and T1PA (28.9 ± 12.7° vs. 21.6 ± 13.6°, p < 0.001) were significantly higher in patients who were discharged to an IPR center/SNF. Additionally, the operating surgeon also significantly influenced the disposition status (p < 0.001). A scoring system of the listed factors was proposed and was validated using univariate logistic regression (OR = 1.55, 95%CI = 1.34-1.78, p < 0.001) and ROC analysis, which revealed a cutoff value of > 6 points as a predictor of non-home discharge (AUC = 0.75, 95%CI = 0.68-0.80, p < 0.001, sensitivity = 63.3%, specificity = 74.1%). The factors in the scoring system were age > 56, comorbidities ≥ 2, hypertension, TIL ≥ 10, operative time > 357 mins, EBL > 1200 mL, preop SVA > 6.6 cm, preop PT > 33.6°, and preop T1PA > 15°. When comparing IPR (n = 71) vs. SNF (n = 38), patients discharged to an SNF were significantly older (74.4 ± 8.6 vs. 70.4 ± 9.1, p = 0.029) and were more likely to be female (89.5% vs. 70.4%, p = 0.024). Conclusions: Approximately 50% of patients were discharged home after ASD surgery. A simple scoring system based on age > 56, comorbidities ≥ 2, hypertension, total instrumented levels ≥ 10, operative time > 357 mins, EBL > 1200 mL, preop SVA > 6.6 cm, preop PT > 33.6°, and preop T1PA > 15° was proposed to predict non-home discharge. These findings may help guide postoperative expectations and resource allocation after ASD surgery.

Combined Anterior-Posterior vs. Posterior-Only Approach in Adult Spinal Deformity Surgery: Which Strategy Is Superior?

Introduction: Whether a combined anterior-posterior (AP) approach offers additional benefits over the posterior-only (P) approach in adult spinal deformity (ASD) surgery remains unknown. In a cohort of patients undergoing ASD surgery, we compared the combined AP vs. the P-only approach in: (1) preoperative/perioperative variables, (2) radiographic measurements, and (3) postoperative outcomes. Methods: A single-institution, retrospective cohort study was performed for patients undergoing ASD surgery from 2009 to 2021. Inclusion criteria were ≥5-level fusion, sagittal/coronal deformity, and 2-year follow-up. The primary exposure was the operative approach: a combined AP approach or P alone. Postoperative outcomes included mechanical complications, reoperation, and minimal clinically important difference (MCID), defined as 30% of patient-reported outcome measures (PROMs). Multivariable linear regression was controlled for age, BMI, and previous fusion. Results: Among 238 patients undergoing ASD surgery, 34 (14.3%) patients underwent the AP approach and 204 (85.7%) underwent the P-only approach. The AP group consisted mostly of anterior lumbar interbody fusion (ALIF) at L5/S1 (73.5%) and/or L4/L5 (38.0%). Preoperatively, the AP group had more previous fusions (64.7% vs. 28.9%, p < 0.001), higher pelvic tilt (PT) (29.6 ± 11.6° vs. 24.6 ± 11.4°, p = 0.037), higher T1 pelvic angle (T1PA) (31.8 ± 12.7° vs. 24.0 ± 13.9°, p = 0.003), less L1-S1 lordosis (-14.7 ± 28.4° vs. -24.3 ± 33.4°, p < 0.039), less L4-S1 lordosis (-25.4 ± 14.7° vs. 31.6 ± 15.5°, p = 0.042), and higher sagittal vertical axis (SVA) (102.6 ± 51.9 vs. 66.4 ± 71.2 mm, p = 0.005). Perioperatively, the AP approach had longer operative time (553.9 ± 177.4 vs. 397.4 ± 129.0 min, p < 0.001), more interbodies placed (100% vs. 17.6%, p < 0.001), and longer length of stay (8.4 ± 10.7 vs. 7.0 ± 9.6 days, p = 0.026). Radiographically, the AP group had more improvement in T1PA (13.4 ± 8.7° vs. 9.5 ± 8.6°, p = 0.005), L1-S1 lordosis (-14.3 ± 25.6° vs. -3.2 ± 20.2°, p < 0.001), L4-S1 lordosis (-4.7 ± 16.4° vs. 3.2 ± 13.7°, p = 0.008), and SVA (65.3 ± 44.8 vs. 44.8 ± 47.7 mm, p = 0.007). These outcomes remained statistically significant in the multivariable analysis controlling for age, BMI, and previous fusion. Postoperatively, no significant differences were found in mechanical complications, reoperations, or MCID of PROMs. Conclusions: Preoperatively, patients undergoing the combined anterior-posterior approach had higher PT, T1PA, and SVA and lower L1-S1 and L4-S1 lordosis than the posterior-only approach. Despite increased operative time and length of stay, the anterior-posterior approach provided greater sagittal correction without any difference in mechanical complications or PROMs.

Artificial Intelligence to Preoperatively Predict Proximal Junction Kyphosis Following Adult Spinal Deformity Surgery: Soft Tissue Imaging May Be Necessary for Accurate Models.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: In a cohort of patients undergoing adult spinal deformity (ASD) surgery, we used artificial intelligence to compare three models of preoperatively predicting radiographic proximal junction kyphosis (PJK) using: (1) traditional demographics and radiographic measurements, (2) raw preoperative scoliosis radiographs, and (3) raw preoperative thoracic magnetic resonance imaging (MRI). SUMMARY OF BACKGROUND DATA: Despite many proposed risk factors, PJK following ASD surgery remains difficult to predict. MATERIALS AND METHODS: A single-institution, retrospective cohort study was undertaken for patients undergoing ASD surgery from 2009 to 2021. PJK was defined as a sagittal Cobb angle of upper-instrumented vertebra (UIV) and UIV+2>10° and a postoperative change in UIV/UIV+2>10°. For model 1, a support vector machine was used to predict PJK within 2 years postoperatively using clinical and traditional sagittal/coronal radiographic variables and intended levels of instrumentation. Next, for model 2, a convolutional neural network (CNN) was trained on raw preoperative lateral and posterior-anterior scoliosis radiographs. Finally, for model 3, a CNN was trained on raw preoperative thoracic T1 MRIs. RESULTS: A total of 191 patients underwent ASD surgery with at least 2-year follow-up and 89 (46.6%) developed radiographic PJK within 2 years. Model 1: Using clinical variables and traditional radiographic measurements, the model achieved a sensitivity: 57.2% and a specificity: 56.3%. Model 2: a CNN with raw scoliosis x-rays predicted PJK with a sensitivity: 68.2% and specificity: 58.3%. Model 3: a CNN with raw thoracic MRIs predicted PJK with average sensitivity: 73.1% and specificity: 79.5%. Finally, an attention map outlined the imaging features used by model 3 elucidated that soft tissue features predominated all true positive PJK predictions. CONCLUSIONS: The use of raw MRIs in an artificial intelligence model improved the accuracy of PJK prediction compared with raw scoliosis radiographs and traditional clinical/radiographic measurements. The improved predictive accuracy using MRI may indicate that PJK is best predicted by soft tissue degeneration and muscle atrophy.

Intrathecal Fentanyl With a Myofascial Plane Block in Open Lumbar Surgeries: A Case Series.

BACKGROUND: Acute postoperative pain control after lumbar surgery is imperative to minimizing long-term narcotic use and associated adverse sequela. The safety of intrathecal morphine for postoperative pain management in spine surgery has been investigated; however, to date, no studies have investigated the safety of intrathecal fentanyl with a myofascial plane (MP) block in lumbar procedures. OBJECTIVE: To assess the safety profile of intrathecal fentanyl with a MP block administered during lumbar surgery and the subsequent utilization of postoperative intravenous opioids. METHODS: An intraoperative intrathecal injection of fentanyl and a MP block was administered in 40 patients undergoing open lumbar reconstructive surgery. The procedure performed was an open decompression with lumbar total joint reconstruction at 1 to 3 lumbar levels. Postoperative complications including urinary retention, respiratory depression, and need for IV opioid use were recorded. RESULTS: Postoperatively, none of the study patients required IV opioid medication for supplemental pain control. Thirty-six patients (85%) were discharged same day or before 23 hours postoperatively. No intrathecal fentanyl-related perioperative complications were noted. None of the 40 listed patients experienced urinary retention or delayed respiratory depression. One patient (2%) experienced orthostatic hypotension at postoperative day 1, which resolved on discontinuation of oral oxycodone. CONCLUSION: Intrathecal fentanyl and MP block may be a safe option for perioperative pain control and may reduce the need for supplemental intravenous opioids without increased risk of respiratory depression, urinary retention, or other side effects. Further studies are necessary to compare the efficacy of intrathecal fentanyl with other analgesia techniques.

Comparing intraoperative parathyroid identification based on surgeon experience versus near infrared autofluorescence detection - A surgeon-blinded multi-centric study.

BACKGROUND: Near infrared autofluorescence (NIRAF) detection has previously demonstrated significant potential for real-time parathyroid gland identification. However, the performance of a NIRAF detection device - PTeye® - remains to be evaluated relative to a surgeon's own ability to identify parathyroid glands. METHODS: Patients eligible for thyroidectomy and/or parathyroidectomy were enrolled under 6 endocrine surgeons at 3 high-volume institutions. Participating surgeons were categorized based on years of experience. All surgeons were blinded to output of PTeye® when identifying tissues. The surgeon's performance for parathyroid discrimination was then compared with PTeye®. Histology served as gold standard for excised specimens, while expert surgeon's opinion was used to validate in-situ tissues. RESULTS: PTeye® achieved 92.7% accuracy across 167 patients recruited. Junior surgeons (<5 years of experience) were found to have lower confidence in parathyroid identification and higher tissue misclassification rate per specimen when compared to PTeye® and senior surgeons (>10 years of experience). CONCLUSIONS: NIRAF detection with PTeye® can be a valuable intraoperative adjunct technology to aid in parathyroid identification for surgeons.

Seated Lateral X-ray Is a Better Stress Radiograph of the Lumbar Spine Compared to Standing Flexion.

STUDY DESIGN: Prospective lumbar radiograph analysis. OBJECTIVE: To compare changes in lumbar lordosis in standing flexion versus seated lateral radiographs. METHODS: Standing lateral, standing flexion, and seated lateral X-rays of the lumbar spine were obtained in patients presenting with low back pain. Trauma, tumor, and revision cases were excluded. Changes in global lumbar as well as segmental lordosis were measured in each position. RESULTS: Seventy adult patients were reviewed. Overall, the greatest changes in lordosis were seen at L4-S1 in both the seated and flexion X-rays (12.5° and 6.3°, respectively). Greater kyphosis was seen in seated versus flexion X-rays (21.6° vs 15.8°); changes in lordosis from L1-L3 were similar in both positions, with little change seen at these levels (approximately 5° to 7°). On subgroup analysis, these differences were magnified in analyzing only patients that moved at least 20° globally, and there were no significant differences between sitting and flexion in "stiff" patients that moved less than 20° globally. CONCLUSION: Greater lumbar kyphosis was seen in the seated position compared to standing flexion, especially from L4-S1. Given these results we suggest the use of seated lateral X-rays to dynamically assess the lumbar spine. These findings may also guide future research into the mechanism and clinical relevance of a stiff versus mobile lumbar spine, as well as into the sensitivity of seated X-rays in detecting instability.

A novel lumbar total joint replacement may be an improvement over fusion for degenerative lumbar conditions: a comparative analysis of patient-reported outcomes at one year.

BACKGROUND CONTEXT: Effective alternatives to lumbar fusion for degenerative conditions have remained elusive. Anterior total disc replacement does not address facet pathology or central/recess stenosis, resulting in limited indications. A posterior-based motion-preserving option that allows for neural decompression, facetectomy, and reconstruction of the disc and facets may have a role. PURPOSE: The purpose was to compare one-year patient-reported outcomes for a novel, all-posterior, lumbar total joint replacement (LTJR - replacing both the disc and facet joints) against transforaminal lumbar interbody fusion (TLIF) for degenerative lumbar conditions warranting fusion (degenerative spondylolisthesis, recurrent disc herniation, severe foraminal stenosis requiring facet removal, and adjacent segment degeneration). STUDY DESIGN/SETTING: A retrospective analysis of prospectively collected data comparing outcomes for LTJR patients to TLIF patients at an academic teaching hospital. PATIENT SAMPLE: Analysis was conducted on 156 adult TLIF patients who were propensity matched to the 52 LTJR patients for a total sample of 208. OUTCOME MEASURES: Self-reported Oswestry Disability Index (ODI) and Numeric Rating Scale (NRS) for back and leg pain were compared preoperatively, 3 months and 1 year after surgery. METHODS: The implant is a motion-preserving lumbar reconstruction that replaces the function of both the disc and facets and is implanted using a bilateral transforaminal approach with complete facetectomies. Adult patients with degenerative lumbar pathology undergoing either LTJR or open TLIF were analyzed. These degenerative conditions included: grade 1 degenerative spondylolisthesis, recurrent disc herniation, adjacent segment disease, disc degeneration with severe foraminal stenosis). Trauma, tumor, grade 2 or higher spondylolisthesis, spinal deformity, and infection cases were excluded. Propensity score matching was performed to ensure parity between the cohorts. Multivariable regression analyses were done to compare the 1-year results as measured by 3 different standards to assess procedure success. RESULTS: At 3 months, both the LTJR and TLIF cohorts showed significant and similar improvements in ODI and NRS back and leg pain. At 1 year, the LTJR cohort showed continued improvement in ODI and NRS back pain, while the TLIF group showed a plateau for ODI, back and leg pain. In a series of three multivariable logistic regressions, LTJR was shown to provide 3.3 times greater odds of achieving the minimal clinical symptom state in disability and pain (ODI <20%, NRS back and leg pain <2) and 2.4 and 4.1 times greater odds of achieving substantial clinical benefit (18% reduction in ODI) and minimal clinically important difference (30% reduction in ODI) as compared to TLIF. CONCLUSIONS: Here we present a comparative analysis for the first 52 patients undergoing a novel, posterior-based LTJR for the lumbar spine versus TLIF for degenerative pathology. The approach for the LTJR allows for wide neural decompression, facetectomy, and complete discectomy, with the implant working to replace the function of the disc and facets to preserve motion. At 1 year, the LTJR cohort showed significant improvement in ODI and NRS back and leg pain as compared to TLIF. These results suggest that wide neural decompression combined with motion preservation using this novel LTJR may represent a viable alternative to TLIF for treating certain degenerative conditions. A prospective controlled trial is under development to further evaluate the efficacy, safety, and durability of this procedure.

Imaging or Fiber Probe-Based Approach? Assessing Different Methods to Detect Near Infrared Autofluorescence for Intraoperative Parathyroid Identification.

BACKGROUND: Near infrared autofluorescence (NIRAF) can guide intraoperative parathyroid gland (PG) identification. NIRAF detection devices typically rely on imaging and fiber probe-based approaches. Imaging modalities provide NIRAF pictures on adjacent display monitors, and fiber probe-based systems measure tissue NIRAF and provide real-time quantitative information to objectively aid PG identification. Both device types recently gained FDA approval for PG identification but have never been compared directly. STUDY DESIGN: Patients undergoing thyroidectomy and/or parathyroidectomy were recruited prospectively. Target tissues were intraoperatively visualized with PDE-Neo II (imaging-based) and concurrently assessed with PTeye (fiber probe-based). For PDE-Neo II, NIRAF images were collected from in situ or excised tissues, alongside the surgeon's interpretation of visualized tissues, and retrospectively analyzed in a blinded fashion. The PTeye was concomitantly used to record NIRAF intensities and ratios from the same tissues in real time. RESULTS: Twenty patients were enrolled for concurrent evaluation with both systems, which included 33 PGs and 19 nonparathyroid sites. NIRAF imaging demonstrated 90.9% sensitivity, 73.7% specificity, and 84.6% accuracy for PG identification when interpreted in real time by the surgeon compared with 81.8% sensitivity, 73.7% specificity, and 78.8% accuracy where images were quantitatively analyzed post hoc by an independent observer. In parallel, NIRAF detection with PTeye yielded 97.0% sensitivity, 84.2% specificity, and 92.3% accuracy in real time for the same specimens. CONCLUSIONS: Both NIRAF-based systems were beneficial for identifying PGs intraoperatively. Although NIRAF imaging provides valuable spatial information to localize PGs, NIRAF detection with fiber probe provides real-time quantitative information to identify PGs in presence of ambient room lights.