The Postoperative Airway Compromise Score-First Steps to Developing a Postoperative Tool for the Assessment of Upper Airway-Related Complications Following Anterior Cervical Spine Surgery.

BACKGROUND: Acute upper airway compromise is a rare but catastrophic complication after anterior cervical discectomy and fusion. This study aims to develop a score to identify patients at risk of acute postoperative airway compromise (PAC). METHODS: Potential risk factors for acute PAC were selected by a modified Delphi process. Ten patients with acute PAC were identified of 1466 patients who underwent elective anterior cervical discectomy and fusion between July 2014 and May 2019. A comparison group was created by a randomized selection process (non-PAC group). Factors associated with PAC and a P value of < 0.10 were entered into a logistic regression model and coefficients contributed to each risk factor's overall score. Calibration of the model was evaluated using the Hosmer-Lemeshow goodness-of-fit test. Quantitative discrimination was calculated, and the final model was internally validated with bootstrap sampling. RESULTS: We identified 18 potential risk factors from our Delphi process, of which 6 factors demonstrated a significant association with airway compromise: age >65 years, current smoking status, American Society of Anesthesiologists class >2, history of a bleeding disorder, surgery of upper subaxial cervical spine (above C4), and duration of surgery >179 minutes. The final prediction model included 5 predictors with very strong performance characteristics. These 5 factors formed the PAC score, with a range from 0 to 100. A score of 20 yielded the greatest balance of sensitivity (80%) and specificity (88%). CONCLUSIONS: The acute PAC score demonstrates strong performance characteristics. The PAC score might help identify patients at risk of upper airway compromise caused by surgical site abnormalities.

Ongoing decision-making dilemma for treatment of de novo spinal infections: a comparison of the Spinal Infection Treatment Evaluation Score with the Spinal Instability Spondylodiscitis Score and Spine Instability Neoplastic Score.

OBJECTIVE: De novo spinal infections are an increasing medical problem. The decision-making for surgical or nonsurgical treatment for de novo spinal infections is often a non-evidence-based process and commonly a case-by-case decision by single physicians. A scoring system based on the latest evidence might help improve the decision-making process compared with other purely radiology-based scoring systems or the judgment of a single senior physician. METHODS: Patients older than 18 years with an infection of the spine who underwent nonsurgical or surgical treatment between 2019 and 2021 were identified. Clinical data for neurological status, pain, and existing comorbidities were gathered and transferred to an anonymous spreadsheet. Patients without an MR image and a CT scan of the affected spine region were excluded from the investigation. A multidisciplinary expert panel used the Spine Instability Neoplastic Score (SINS), Spinal Instability Spondylodiscitis Score (SISS), and Spinal Infection Treatment Evaluation Score (SITE Score), previously developed by the authors' group, on every clinical case. Each physician of the expert panel gave an individual treatment recommendation for surgical or nonsurgical treatment for each patient. Treatment recommendations formed the expert panel opinion, which was used to calculate predictive validities for each score. RESULTS: A total of 263 patients with spinal infections were identified. After the exclusion of doubled patients, patients without de novo infections, or those without CT and MRI scans, 123 patients remained for the investigation. Overall, 70.70% of patients were treated surgically and 29.30% were treated nonoperatively. Intraclass correlation coefficients (ICCs) for the SITE Score, SINS, and SISS were 0.94 (95% CI 0.91-0.95, p < 0.01), 0.65 (95% CI 0.91-0.83, p < 0.01), and 0.80 (95% CI 0.91-0.89, p < 0.01). In comparison with the expert panel decision, the SITE Score reached a sensitivity of 96.97% and a specificity of 81.90% for all included patients. For potentially unstable and unstable lesions, the SISS and the SINS yielded sensitivities of 84.42% and 64.07%, respectively, and specificities of 31.16% and 56.52%, respectively. The SITE Score showed higher overall sensitivity with 97.53% and a higher specificity for patients with epidural abscesses (75.00%) compared with potentially unstable and unstable lesions for the SINS and the SISS. The SITE Score showed a significantly higher agreement for the definitive treatment decision regarding the expert panel decision, compared with the decision by a single physician for patients with spondylodiscitis, discitis, or spinal osteomyelitis. CONCLUSIONS: The SITE Score shows high sensitivity and specificity regarding the treatment recommendation by a multidisciplinary expert panel. The SITE Score shows higher predictive validity compared with radiology-based scoring systems or a single physician and demonstrates a high validity for patients with epidural abscesses.

Resource Utilization following Anterior Versus Posterior Cervical Decompression and Fusion for Acute Central Cord Syndrome.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The purpose of this study is to compare the impact of anterior cervical decompression and fusion (ACDF) versus posterior cervical decompression and fusion (PCDF) for the treatment of acute traumatic central cord syndrome (CCS) on hospital episodes of care in terms of (1) cost, (2) length of hospital stay, and (3) discharge destination. SUMMARY OF BACKGROUND DATA: Acute traumatic CCS is the most common form of spinal cord injury in the United States. CCS is commonly treated with surgical decompression and fusion. Hospital resource utilization based on surgical approach remains unclear. METHODS: Patients undergoing ACDF and PCDF for acute traumatic CCS were identified using the 2019 Medicare Provider Analysis and Review Limited Data Set and Centers for Medicare and Medicaid Services 2019 Impact File. Multivariate models for hospital cost of care, length of stay, and discharge destination were performed, controlling for confounders. Subanalysis of accommodation and revenue center cost drivers was performed. RESULTS: There were 1474 cases that met inclusion criteria: 673 ACDF (45.7%) and 801 PCDF (54.3%). ACDF was independently associated with a decreased cost of $9802 (P<0.001) and a 59.2% decreased risk of discharge to nonhome destinations (adjusted odds ratio: 0.408, P<0.001). The difference in length of stay was not statistically significant. On subanalysis of cost drivers, ACDF was associated with decreased charges ($55,736, P<0.001) compared with PCDF, the largest drivers being the intensive care unit ($15,873, 28% of total charges, P<0.001) and medical/surgical supply charges ($19,651, 35% of total charges, P<0.001). CONCLUSIONS: For treatment of acute traumatic CCS, ACDF was associated with almost $10,000 less expensive cost of care and a 60% decreased risk of discharge to nonhome destination compared with PCDF. The largest cost drivers appear to be ICU and medical/surgical-related. These findings may inform value-based decisions regarding the treatment of acute traumatic CCS. However, injury and patient clinical factors should always be prioritized in surgical decision-making, and increased granularity in reimbursement policies is needed to prevent financial disincentives in the treatment of patients with CCS better addressed with posterior approach-surgery.

Posterior pelvic ring injuries, lumbosacral junction instabilities and stabilization techniques for spinopelvic dissociation: a narrative review.

INTRODUCTION: From transiliac Harrington rods to minimally invasive (MIS) percutaneous 3D-navigated transsacral-transiliac screw (TTS) fixation, concepts of fixation methods in pelvic injuries with spinopelvic dissociation (SPD) are steadily redefined. This narrative review examines the literature of recent years regarding surgical treatment options and trends in SPD, outlining risks and benefits of each treatment option and addressing biomechanical aspects of sacral injuries and common classification systems. MATERIALS AND METHODS: A literature search on the search across relevant online databases was conducted. As a scale for quality assessment, the SANRA-scoring system was taken into account. RESULTS: Sacral Isler type 1 injuries of the LPJ in U- and H-type fractures are frequently treated with stand-alone TTS. Fractures with higher instability (Isler types 2 and 3) require unilateral or bilateral LPF, subject to side involvement, as a buttressing construct, or triangular fixation as additional compression and neutralization, determined by fracture radiation. A more comprehensive classification from which to derive stabilization options is provided by the 2023 301SPD classification. MIS techniques are on the rise and offer shorter OR time, less blood loss, fewer infections, and fewer wound complications. It is advisable to implement MIS techniques as much as possible, as long as decompression is not required and closed fracture reduction succeeds satisfactorily. CONCLUSION: SPD is characteristic of severe injuries, mostly in polytraumatized patients. The complication rates are decreasing due to the increasing adaptation of MIS techniques.

Elective Single-Level Primary Anterior Cervical Decompression and Fusion for Degenerative Spondylotic Cervical Myelopathy is Associated With Decreased Resource Utilization Versus Posterior Cervical Decompression and Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To compare elective single-level anterior cervical discectomy and fusion (ACDF) versus posterior cervical decompression and fusion (PCDF) for degenerative cervical myelopathy (DCM) in terms of (1) cost, (2) length of hospital stay, and (3) discharge destination in Medicare patients. A sub-analysis of potential cost drivers was also performed. BACKGROUND: In the era of value-based medicine, there is substantial interest in reducing the cost of care. Both ACDF and PCDF are used to treat DCM but carry different morbidity and risk profiles that can impact hospital resource utilization. However, this has not been assessed on a national level. METHODS: Patients undergoing single-level elective ACDF and PCDF surgery were identified using the 2019 Medicare Provider Analysis and Review (MedPAR) Limited Data Set (LDS) and Centers for Medicare and Medicaid Services (CMS) 2019 Impact File. Multivariate models of hospital cost of care, length of stay, and discharge destination were performed, controlling for confounders. A univariate sub-analysis of 9 revenue centers was performed. RESULTS: In all, 3942 patients met the inclusion criteria. The mean cost of elective single-level cervical fusion for myelopathy was $18,084±10,783, and the mean length of stay was 2.45±2.95 d. On multivariate analysis, ACDF was independently associated with decreased cost of $5,814 (P<0.001), shorter length of stay by 1.1 days (P<0.001), and decreased risk of nonhome discharge destination by 58% (adjusted odds ratio: 0.422, P<0.001).On sub-analysis of 9 revenue centers, medical/surgical supply ($10,497, 44%), operating room charges ($5401, 23%), and accommodations ($3999, 17%) were the largest drivers of charge differences. CONCLUSIONS: Single-level elective primary ACDF for DCM was independently associated with decreased cost, decreased hospital length of stay, and a lower rate of nonhome discharge compared with PCDF. Medical and surgical supply, operating room, and accommodation differences between ACDF and PCDF are potential areas for intervention. Increased granularity in reimbursement structures is warranted to prevent the creation of disincentives to the treatment of patients with DCM with pathology that is better addressed with PCDF. LEVEL OF EVIDENCE: Level-III Retrospective Cohort Study.

Revisiting Anticoagulation in Spine Surgery: Balancing Venous Thromboembolic Events and Epidural Hematoma.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: Venous thromboembolic events (VTE) and post-operative epidural hematoma (EDH) are significant complications after spine surgery. Guidelines for chemoprophylaxis are controversial and variability amongst surgeons remains. The objective of this study was to establish the incidence of clinical VTE and EDH at our institution and evaluate the association of chemoprophylaxis with clinical VTE and EDH. METHODS: We conducted a retrospective cohort study of patients undergoing spine surgery at a high-volume tertiary care center in Seattle, WA between January 2016 and December 2019. The Premier Health Care Database and Agency for Healthcare Research and Quality (AHRQ) patient indicators PSI-9 (Perioperative hemorrhage and hematoma) and PSI-12(Perioperative PE or DVT) were used to identify patients experiencing VTE and/or post-operative EDH. The primary outcome was the incidence of clinical VTE and EDH in post-operative spine patients. Secondary outcomes included the association of chemoprophylaxis with clinical VTE and EDH. RESULTS: From 2016 to 2019, 4587 patients underwent spine surgery, totaling 4764 hospital stays. The incidence of clinical VTE was .21% (10/4764) and the incidence of EDH was .10% (5/4764). Most hemorrhages occurred prior to the initiation of chemoprophylaxis. One patient with EDH received chemoprophylaxis prior to hemorrhage. CONCLUSIONS: The rate of post-operative clinical VTE and EDH in spine surgery is low. Despite early initiation of chemoprophylaxis after major spine surgery we did not appreciate a high rate of EDH. We attribute our low rate of clinical VTE to multimodal prophylaxis with SCDs, early mobilization and chemoprophylaxis on post-operative day 1.

Cage subsidence-A multifactorial matter!

STUDY DESIGN: Retrospective cohort study OBJECTIVE: Wider cages are associated with improved decompression and reduced subsidence, but variation in cage physical properties limits consistent outcome analysis after thoracolumbar interbody fusion. This study investigated cage subsidence and its relationship to lateral and posterior approaches with a focus on the hypothesis that the larger surface area of lateral cages results in lower subsidence rates. METHODS: This study retrospectively reviewed 194 patients who underwent interbody fusion between 2016 and 2019 with a primary outcome of cage subsidence. Secondary outcomes were cage distribution (patients, approaches, expandability), cage dimensions, t­scores, length of hospital stay, blood loss, surgical time, and pelvic incidence-lumbar lordosis (PI-LL) mismatch. RESULTS: Medical records were reviewed for 194 patients receiving 387 cages at 379 disc levels. Subsidence was identified in 35.1% of lateral cages, 40.9% of posterior cages, and 36.3% of all cages. Lower surface area (p = 0.008) and cage expandability were associated with subsidence risk. Lower anteroposterior cage length proved to be a significant factor in the subsidence of posteriorly placed cages (p = 0.007). Osteopenic and osteoporotic patients experienced cage subsidence 36.8% of the time compared to 3.5% of patients with normal t­scores (p = 0.001). Cage subsidence correlated with postoperative deterioration of the PI-LL mismatch (p = 0.03). Patients receiving fusion augmentation with bone morphogenic protein experienced higher fusion rates (p < 0.01). CONCLUSION: Cage subsidence is a common complication that can significantly impact operative outcomes following thoracolumbar interbody fusion. Low t­scores, smaller surface area, cage expandability, and lower cage length in posterior approaches contribute significantly to cage subsidence.

Impact of Race/Ethnicity on Hospital Resource Utilization After Elective Anterior Cervical Decompression and Fusion for Degenerative Myelopathy.

INTRODUCTION: With the advent of bundled care payments for spine surgery, there is increasing scrutiny on the costs and resource utilization associated with surgical care. The purpose of this study was to compare (1) the total cost of the hospital episode of care and (2) discharge destination between White, Black, and Hispanic patients receiving elective anterior cervical decompression and fusion for degenerative cervical myelopathy (DCM) in Medicare patients. METHODS: The 2019 Medicare Provider Analysis and Review Limited Data Set and the 2019 Impact File were used for this project. Multivariate models were created for total cost and discharge destination, controlling for confounders found on univariate analysis. We then performed a subanalysis for differences in specific cost-center charges. RESULTS: There were 11,506 White (85.4%), 1,707 Black (12.7%), and 261 Hispanic (1.9%) patients identified. There were 6,447 males (47.8%) and 7,027 females (52.2%). Most patients were between 65 to 74 years of age (n = 7,101, 52.7%). The mean cost of the hospital episode was $20,919 ± 11,848. Most patients were discharged home (n = 11,584, 86.0%). Race/ethnicity was independently associated with an increased cost of care (Black: $783, Hispanic: $1,566, P = 0.001) and an increased likelihood of nonhome discharge (Black: adjusted odds ratio: 1.990, P < 0.001, Hispanic: adjusted odds ratio: 1.822, P < 0.001) compared with White patients. Compared with White patients, Black patients were charged more for accommodations ($1808), less for supplies (-$1780), and less for operating room (-$1072), whereas Hispanic patients were charged more ($3556, $7923, and $5162, respectively, P < 0.05). CONCLUSION: Black and Hispanic race/ethnicity were found to be independently associated with an increased cost of care and risk for nonhome discharge after elective anterior cervical decompression and fusion for DCM compared with White patients. The largest drivers of this disparity appear to be accommodation, medical/surgical supply, and operating room-related charges. Further analysis of these racial disparities should be performed to improve value and equity of spine care for DCM.

A novel scoring system concept for de novo spinal infection treatment, the Spinal Infection Treatment Evaluation Score (SITE Score): a proof-of-concept study.

OBJECTIVE: De novo infections of the spine are an increasing healthcare problem. The decision for nonsurgical or surgical treatment is often made case by case on the basis of physician experience, specialty, or practice affiliation rather than evidence-based medicine. To create a more systematic foundation for surgical assessments of de novo spinal infections, the authors applied a formal validation process toward developing a spinal infection scoring system using principles gained from other spine severity scoring systems like the Spine Instability Neoplastic Score, Thoracolumbar Injury Classification and Severity Score, and AO Spine classification of thoracolumbar injuries. They utilized an expert panel and literature reviews to develop a severity scale called the "Spinal Infection Treatment Evaluation Score" (SITE Score). METHODS: The authors conducted an evidence-based process of combining literature reviews, extracting key elements from previous scoring systems, and obtaining iterative expert panel input while following a formal Delphi process. The resulting basic SITE scoring system was tested on selected de novo spinal infection cases and serially refined by an international multidisciplinary expert panel. Intra- and interobserver reliabilities were calculated using the intraclass correlation coefficient (ICC) and Fleiss' and Cohen's kappa, respectively. A receiver operating characteristic analysis was performed for cutoff value analysis. The predictive validity was assessed through cross-tabulation analysis. RESULTS: The conceptual SITE scoring system combines the key variables of neurological symptoms, infection location, radiological variables for instability and impingement of neural elements, pain, and patient comorbidities. Ten patients formed the first cohort of de novo spinal infections, which was used to validate the conceptual scoring system. A second cohort of 30 patients with de novo spinal infections, including the 10 patients from the first cohort, was utilized to validate the SITE Score. Mean scores of 6.73 ± 1.5 and 6.90 ± 3.61 were found in the first and second cohorts, respectively. The ICCs for the total score were 0.989 (95% CI 0.975-0.997, p < 0.01) in the first round of scoring system validation, 0.992 (95% CI 0.981-0.998, p < 0.01) in the second round, and 0.961 (95% CI 0.929-0.980, p < 0.01) in the third round. The mean intraobserver reliability was 0.851 ± 0.089 in the third validation round. The SITE Score yielded a sensitivity of 97.77% ± 3.87% and a specificity of 95.53% ± 3.87% in the last validation round for the panel treatment decision. CONCLUSIONS: The SITE scoring concept showed statistically meaningful reliability parameters. Hopefully, this effort will provide a foundation for a future evidence-based decision aid for treating de novo spinal infections. The SITE Score showed promising inter- and intraobserver reliability. It could serve as a helpful tool to guide physicians' therapeutic decisions in managing de novo spinal infections and help in comparison studies to better understand disease severity and outcomes.

Who Needs Surgical Stabilization for Pyogenic Spondylodiscitis? Retrospective Analysis of Non-Surgically Treated Patients.

STUDY DESIGN: Retrospective case series analysis. OBJECTIVE: To identify relevant clinical and radiographic markers for patients presenting with infectious spondylo-discitis associated with spinal instability directly related to the infectious process. METHODS: We evaluated patients presenting with de-novo intervertebral discitis or vertebral osteomyelitis /discitis (VOD) who initiated non-surgical treatment. Patients who failed conservative treatment and required stabilization surgery within 90 days were defined as "failed treatment group" (FTG). Patients who experienced an uneventful course served as controls and were labeled as "nonsurgical group" (NSG). A wide array of baseline clinical and radiographic parameters was retrieved and compared between 2 groups. RESULTS: Overall 35 patients had initiated non-surgical treatment for VOD. 25 patients had an uneventful course (NSG), while 10 patients failed conservative treatment ("FTG") within 90 days. Factors found to be associated with poorer outcome were intra-venous drug abuse (IVDA) as well as the presence of fever upon initial presentation. Radiographically, involvement of the same-level facets and the extent of caudal and rostral VB involvement in both MRI and CT were found to be significantly associated with poorer clinical and radiographic outcome. CONCLUSIONS: We show that clinical factors such as IVDA status and fever as well as the extent of osseous and posterior element involvement may prove to be helpful in favoring surgical treatment early on in the management of spinal infections.

Comparing Combined Anterior and Posterior to Posterior-Only Decompression and Fusion Crossing the Cervico-Thoracic Junction in Octogenarians.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The purpose of the study was to compare early complication, morbidity and mortality risks associated with fusion surgery crossing the cervico-thoracic junction in patients aged over 80 years undergoing combined anterior and posterior approach versus a posterior-only approach. METHODS: We retrospectively identified octogenarian patients with myelopathy who underwent fusion crossing the cervico-thoracic junction. Patient demographics, Nurick score, surgical characteristics, complications, hospital course, early outcome and 90-day mortality were collected. Comorbidities were classified using the age-adjusted Charlson Comorbidity Index (AACCI). Radiographic measurements for deformity correction included the C2-C7 sagittal Cobb angle, C2-7 sagittal vertical axis and T1 slope pre- and postoperatively. RESULTS: Out of 8,521 surgically treated patients, 12 octogenarian patients had a combined anterior and posterior approach (AP group) and 14 were treated from posterior-only (P group). Mean age was 81.4 ± 1.2 and 82.5 ± 2.7 years, respectively. There was no significant difference in Nurick scores between the groups (P > 0.05). The major complication risk in the AP group was significantly higher, requiring PEG tube placement due to severe dysphagia in 4 patients (33%) compared to none in the P group. A greater improvement in cervical lordosis could be achieved through a combined approach. The 90-day mortality risk was 8% for the AP group and 0% for the P group. CONCLUSIONS: A combined anterior and posterior approach is associated with a significantly higher major complication rate and can result in severe dysphagia requiring PEG tube placement in one-third of patients over 80 years of age.

An Assessment of the Safety of Surgery and Hardware Placement in de-novo Spinal Infections. A Systematic Review and Meta-Analysis of the Literature.

OBJECTIVES: Primary objectives were outcomes comparison of instrumented surgery used for de-novo spinal infections in terms of infection recurrence, reoperations, primary failure, mortality, and length of stay relative to non-instrumented surgery. Secondary objectives were outcomes for surgical and non-surgical treatment of de-novo spinal infections regarding recurrence of infection, mortality, quality of life, and length-of-stay. METHODS: A systematic literature review was performed using the PubMed database. Studies comparing outcome variables of patients with de-novo spinal infections (DNSI) treated with and without instrumentation and surgical versus non-surgical treatment were included. Studies primarily focusing on epidural abscesses or non-de-novo infections were excluded. A meta-analysis was performed for infection recurrence, reoperation, primary treatment failure, mortality, and quality-of-life parameters. RESULTS: A total of 17 retrospective studies with 2.069 patients met the inclusion criteria. 1.378 patients received surgical treatment with or without instrumentation; 676 patients were treated non-surgically. For the comparison of instrumented to non-instrumented surgery Odds-Ratios were .98 (P = .95) for infection recurrence, .83 (P = .92) for primary failure, .53 (P = .02) for mortality and .32 (P = .05) for reoperation. For the comparison of non-surgical to surgical treatment, Odds-Ratios were .98 (P = .95) for infection recurrence, and 1.05 (P = .89) for mortality. CONCLUSION: Available data support that instrumented surgery can be performed safely without higher rates of infection recurrence or primary failure and lower reoperation and mortality rates compared to nonsurgical treatment for DNSI. Furthermore, spine surgical treatment may generally be performed without higher risk of infection recurrence and mortality and better quality-of-life outcomes compared to generic non-surgical treatment.

The Risk of Adverse Events in Smokers Undergoing Spinal Fusion: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVES: Determine if tobacco use is associated with increased risk of postoperative adverse events within 90 days in patients undergoing spinal fusion surgery. METHODS: Databases were queried to identify cohort studies that directly compared smokers with non-smokers and provided the absolute number of adverse events and the population at risk. Data quality was evaluated using the Quality in Prognosis Studies tool. Risk ratios (RR) and 95% confidence intervals were calculated and compared between studies. The grading of recommendation, assessment, development and evaluation (GRADE) criteria were used to assess the strength of the evidence. RESULTS: Seventeen studies assessing 37 897 participants met the inclusion criteria. Of these, 10 031 (26.5%) were smokers and 27 866 (73.5%) were nonsmokers. The mean age for the study population was 58 years, and 45% were males. Smoking was not associated with increased risk of one or more major adverse events within 90 days following spine surgery (seven studies, pooled RR 1.13, 95% CI [.75-1.71], I2 = 41%). However, smoking was significantly associated with one or more major adverse events in ≤2 level fusion (three studies, pooled RR 2.46, 95% CI [1.18-5.12], I2 = 0%), but not in fusions of ≥3 levels (four studies, pooled RR .87, 95% CI [.70-1.08], I2 = 0%). Additionally, there was no statistically significant association between smoking and any adverse event, nor increased reoperation risk due to adverse events. CONCLUSIONS: In this meta-analysis, tobacco use was not associated with a statistically significant increased risk of adverse events within 90 days in patients undergoing spinal fusion surgery. Our results are limited by the variable reporting methodology for both complication rates as well as smoking incidence between the included individual studies.

Lumbar Decompression versus Decompression and Fusion in Octogenarians: Complications and Clinical Course With 3-Year Follow-Up.

STUDY DESIGN: Retrospective review. OBJECTIVES: This study aimed to assess and compare the clinical course and complications between surgical decompression and decompression with fusion in lumbar spine patients aged ≥80 years. METHODS: A retrospective review of electronic medical records at a single institution was conducted between September 2005 and December 2021. Logistic regression was used to identify potential risk factors for the occurrence of complications. RESULTS: Over a 16-year period, 327 patients were allocated to the decompression only group and 89 patients were allocated to the decompression and instrumented fusion group. The study had a mean follow-up duration of 36.7 ± 12.4 months. When assessing the CCI, patients of the instrumentation group had fewer comorbidities (8.9 ± .5 points vs 6.2 ± 1.5 points; P < .001), significantly longer surgical duration (290 ± 106 minutes vs 145 ±50.2 minutes; P < .001), significantly higher volume of intraoperative blood loss (791 ± 319.3 ml vs 336.1 ± 150.8 ml; P < .001), more frequent intraoperative blood transfusion (7 ± 2.1% vs 16± 18.0%; P < .001), and extended stays in the intensive care unit and hospitalization rates. Logistic regression analysis revealed that surgical duration and extent of surgery were unique risk factors for the occurrence of complications. CONCLUSIONS: Lumbar decompression and additional fusion in octogenarians are considerable treatment techniques; albeit associated with increased complication risks. Prolonged operative time and extent of surgery are critical confounding factors associated with higher rates of postoperative complications. Surgery should only be performed after careful outweighing of potential benefits and risks.

Cervical Spine Research Society-Cervical Stiffness Disability Index (CSRS-CSDI): Validation of a Novel Scoring System Quantifying the Effect of Postarthrodesis Cervical Stiffness on Patient Quality of Life.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: The aim was to create and validate a novel patient-reported outcome measure (PROM) focusing on stiffness-related patient functional limitations after cervical spine fusion. SUMMARY OF BACKGROUND DATA: Cervical arthrodesis is a common treatment for myelopathy/radiculopathy, however, results in increased neck stiffness as a collateral outcome. No current PROM exists quantifying the impact of postoperative stiffness on patient function. METHODS: The Cervical Spine Research Society-Cervical Stiffness Disability Index (CSRS-CSDI) was created through a modified Delphi process. The resultant 10-item questionnaire yields a score out of 100 with higher scores indicating increased functional difficulty related to neck stiffness. Cross-sectional study of control and postoperative patients was completed for CSRS-CSDI validation. Retest reliability (intraclass correlation coefficient), internal consistency (Cronbach alpha), responsiveness (levels fused vs. CSRS-CSDI scores), and discriminatory validation (CSRS-CSDI vs. neck disability index) scores) were completed. RESULTS: Fifty-seven surgical and 24 control patients completed the questionnaire. Surgical patients underwent a variety of procedures: 11 (19%) motion preserving operations, nine (16%) subaxial 1-2 level fusions, seven (12%) subaxial 3-5 level fusions, five (9%) C1-subaxial cervical spine fusions, 20 (35%) C2-upper thoracic spine fusions, five (9%) occiput-subaxial or thoracic spine fusions. The questionnaire demonstrated high internal consistency (Cronbach alpha=0.92) and retest reliability (intraclass correlation coefficient=0.95, P <0.001). Good responsiveness validity with a significant difference between fusion cohorts was found ( P <0.001, rs =0.63). Patient CSRS-CSDI scores also correlated with neck disability index scores recorded ( P <0.001, r =0.70). CONCLUSION: This is the first study to create a PROM addressing the functional impact of cervical stiffness following surgical arthrodesis. The CSRS-CSDI was a reliable and valid measure of postoperative stiffness impact on patient function. This may prove useful in counseling patients regarding their expected outcomes with further investigation demonstrating its value in a prospective fashion.

Vasoplegia Following Complex Spine Surgery: Incidence and Risk.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Vasoplegia is a life-threatening form of distributive or vasodilatory shock that is characterized by reduced systemic vascular resistance with resultant hypotension and normal to elevated cardiac output affecting morbidity and mortality. Vasoplegia in the context of Spine Surgery has not been described previously. The purpose of this case series is to determine incidence, risk factors, complications and postoperative outcome in patients with vasoplegia after complex multi-level thoraco-lumbar spine surgery. METHODS: A retrospective review of the electronic medical records at our institution was conducted between January 2014 and June 2018. All patients undergoing multi-level spine surgery (>6 levels) were screened for intraoperative hypotension. Patient demographics, surgical characteristics, neurological status, blood loss, risk factors, medical treatment, complications, hospital course and mortality were collected. All patients included in this study had a minimum follow-up period of 3 months. RESULTS: Out of 8521 surgically treated patients, 994 patients with multi-level thoraco-lumbar spine surgery were identified. A total of 41 patients had intraoperative hypotensive events. Of those, 5 patients with vasoplegia could be identified after elimination of all other potential contributing factors. Vasoplegia did not influence the neurological outcome. One major and three minor complications occurred. All patients showed full recovery. The risk factors identified for vasoplegia include prolonged surgery with osteotomies. CONCLUSIONS: Vasoplegia is a rare condition with an incidence of .6%. Patients experiencing vasoplegia did not appear to experience worse surgical outcomes. The use of special intraoperative hemodynamic monitoring should be considered in selected cases.

Decompression only versus fusion in octogenarians with spinal epidural abscesses: early complications, clinical and radiological outcome with 2-year follow-up.

Despite increased life expectancy due to health care quality improvements globally, pyogenic vertebral osteomyelitis (PVO) treatment with a spinal epidural abscess (SEA) remains challenging in patients older than 80 years. We aimed to assess octogenarians for PVO prevalence with SEA and compare after-surgery clinical outcomes of decompression and decompression and instrumentation. A retrospective review of electronic medical records at a single institution was conducted between September 2005 and December 2020. Patient demographics, surgical characteristics, complications, hospital course, and 90-day mortality were collected. Comorbidities were assessed using the age-adjusted Charlson comorbidity index (CCI). Over 16 years, 35 patients aged ≥80 years with PVO and SEA were identified. Eighteen patients underwent surgical decompression ("decompression group"), and 17 underwent surgical decompression with instrumentation ("instrumentation group"). Both groups had a CCI >6 (mean±SD, 8.9±2.1 vs. 9.6±2.7, respectively; p=0.065). Instrumentation group patients had a significantly longer hospital stay but no ICU stay. In-hospital and 90-days mortality rates were similar in both groups. The mean follow-up was 26.6±12.4 months. No further surgeries were performed. Infection levels and neurological status were improved in both groups at discharge. At the second-stage analysis, significant improvements in the blood infection parameters and the neurological status were detected in the decompression group. Octogenarians with PVO and SEA have a high adverse events risk after surgical procedures. Surgical decompression might contribute to earlier clinical recovery in older patients. Thus, the surgical approach should be discussed with patients and their relatives and be carefully weighed.

The lexicon of multirod constructs in adult spinal deformity: a concise description of when, why, and how.

The use of multirod constructs in the setting of adult spinal deformity (ASD) began to prevent rod fracture and pseudarthrosis near the site of pedicle subtraction osteotomies (PSOs) and 3-column osteotomies (3COs). However, there has been unclear and inconsistent nomenclature, both clinically and in the literature, for the various techniques of supplemental rod implantation. In this review the authors aim to provide the first succinct lexicon of multirod constructs available for the treatment of ASD, providing a universal nomenclature and definition for each type of supplementary rod. The primary rod of ASD constructs is the longest rod that typically spans from the bottom of the construct to the upper instrumented vertebrae. The secondary rod is shorter than the primary rod, but is connected directly to pedicle screws, albeit fewer of them, and connects to the primary rod via lateral connectors or cross-linkers. Satellite rods are a 4-rod technique in which 2 rods span only the site of a 3CO via pedicle screws at the levels above and below, and are not connected to the primary rod (hence the term "satellite"). Accessory rods are connected to the primary rods via side connectors and buttress the primary rod in areas of high rod strain, such as at a 3CO or the lumbosacral junction. Delta rods span the site of a 3CO, typically a PSO, and are not contoured to the newly restored lordosis of the spine, thus buttressing the primary rod above and below a 3CO. The kickstand rod itself functions as an additional means of restoring coronal balance and is secured to a newly placed iliac screw on the side of truncal shift and connected to the primary rod; distracting against the kickstand then helps to correct the concavity of a coronal curve. The use of multirod constructs has dramatically increased over the last several years in parallel with the increasing prevalence of ASD correction surgery. However, ambiguity persists both clinically and in the literature regarding the nomenclature of each supplemental rod. This nomenclature of supplemental rods should help unify the lexicon of multirod constructs and generalize their usage in a variety of scientific and clinical scenarios.

Iliac Screw Fixation Revisited: Improved Clinical and Radiologic Outcomes Using a Modified Iliac Screw Fixation Technique.

STUDY DESIGN: A retrospective study. OBJECTIVE: To describe the modified iliac screw (mILS) technique and compare it to other spinopelvic fixation techniques in terms of wound healing complications, hardware prominence, and failure. SUMMARY OF BACKGROUND DATA: The traditional entry point of an iliac screw often causes postoperative gluteal pain from the prominent screw head. The use of an offset connector also adds a point of weakness to the construct. By choosing a different screw entry point offset connectors can be avoided, and the screw head itself is less prominent, thereby reducing postoperative discomfort. MATERIALS AND METHODS: A retrospective analysis was performed of adult patients undergoing lumbopelvic fixation (LPF) between January 2014 and June 2019. Patients were grouped into 1 of 3 groups based on the technique of pelvic fixation: S2 alar-iliac (S2AI) screw, traditional iliac screw (tILS), and mILS. The primary outcome parameter was the minimal distance from screw head to skin. Secondary outcome parameters were instrumentation loosening/failure, adjacent level fractures, pseudoarthrosis, and medial or lateral iliac screw perforation. RESULTS: A total of 190 patients undergoing LPF were included in the following 3 groups: mILS group (n=113), tILS group (n=40), and S2AI group (n=37). The mean minimal distance from screw head to skin in the mILS group was 31.3 mm compared with 23.7 mm in the tILS group (P<0.00199). No statistically significant differences were found when comparing the 3 groups with respect to complications. The mILS group did not show any cases of prominent instrumentation and had the lowest rate of instrumentation failure. CONCLUSIONS: The mILS technique is an acceptable alternative for LPF, offering the benefits of iliac screw fixation while avoiding offset connectors and screw prominence complications associated with tILS. LEVEL OF EVIDENCE: Level III.