Race, Ethnicity, and Gender Representation Among US Academic Spine Surgeons.

BACKGROUND: Although diversity has improved across certain orthopaedic subspecialties, enhancing diversity within spine surgery has remained a challenge. We aimed to investigate the current state of sex, racial, and ethnic diversity among academic orthopaedic spine surgeons in the United States. METHODS: In January 2024, a cross-sectional analysis of orthopaedic spine surgery faculty in the United States was conducted using the Doximity database to identify eligible surgeons. Fellowship-trained orthopaedic spine surgeons (professor, associate professor, and assistant professor) who graduated residency between 1990 and 2022 were included. Race, sex, academic rank, residency year of graduation, and H-Index scores were recorded using publicly available information from faculty profile pages and the Doximity database. RESULTS: Four hundred fifty-two spine faculty were included in the analysis: 95.1% men and 4.84% women. Across race and ethnicity, 315 surgeons (69.7%) were White, 111 (24.6%) Asian, 15 (3.32%) Black or African American, and 11 (2.43%) Hispanic or Latino or of Spanish origin. Of the 101 professor-level surgeons, 3 (2.97%) were Black men. Among female professors, none were Black, Asian, or Hispanic/Latino. No Hispanic or Latino female professors, associate professors, or assistant professors were identified. The sex and race/ethnicity demographics that have increased in percentage over time include White women (0.92% to 6.08%), Asian men (11.0% to 26.5%), Asian women (0% to 1.66%), and Hispanic/Latino men (1.83% to 3.87%). The surgeon demographic groups that demonstrated minimal fluctuations over time included Black men, Black women, and Hispanic/Latino women. CONCLUSION: Our findings demonstrate that underrepresentation among academic spine surgeons remains an ongoing challenge that warrants increased attention. Enhancing the representation of Black and Hispanic men, as well as Black, Asian, and Hispanic women, in spine surgery requires a deliberate effort at every level of orthopaedic training.

Socioeconomic Status Impacts Length of Stay and Non-Home Discharge Disposition after Posterior Cervical Decompression and Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To examine how community-level economic disadvantage impacts short-term outcomes following posterior cervical decompression and fusion (PCDF) for cervical spondylotic myelopathy. SUMMARY OF BACKGROUND DATA: The effects of socioeconomic factors, measured by the Distress Community Index (DCI), on postoperative outcomes after PCDF are underexplored. By understanding the impact of socioeconomic status (SES) on PCDF outcomes, disparities in care can be addressed. MATERIALS AND METHODS: Retrospective review of 554 patients who underwent PCDF for cervical spondylotic myelopathy between 2017 and 2022. SES was assessed using DCI obtained from patient zip codes. Patients were stratified into quintiles from Prosperous to Distressed based on DCI. Bivariate analyses and multivariate regressions were performed to evaluate the associations between social determinants of health and surgical outcomes including length of stay, home discharge, complications, and readmissions. RESULTS: Patients living in At-Risk/Distressed communities were more likely to be Black (53.3%). Patients living in At-Risk/Distressed communities had the longest hospitalization (6.24 d vs. Prosperous: 3.92, P=0.006). Significantly less At-Risk/Distressed patients were discharged home without additional services (37.3% vs. Mid-Tier: 52.5% vs. Comfortable: 53.4% vs. Prosperous: 56.4%, P<0.001). On multivariate analysis, residing in an At-Risk/Distressed community was independently associated with non-home discharge (odds ratio (OR): 2.28, P=0.007) and longer length of stay (E:1.54, P=0.017). CONCLUSION: Patients from socioeconomically disadvantaged communities experience longer hospitalizations and are more likely to be discharged to a rehabilitation or skilled nursing facility following PCDF. Social and economic barriers should be addressed as part of presurgical counseling and planning in elective spine surgery to mitigate these disparities and improve the quality and value of health care delivery, regardless of socioeconomic status.

The attainment of a patient acceptable symptom state in patients undergoing revision spine fusion.

INTRODUCTION: Revision lumbar fusion is most commonly due to nonunion, adjacent segment disease (ASD), or recurrent stenosis, but it is unclear if diagnosis affects patient outcomes. The primary aim of this study was to assess whether patients achieved the patient acceptable symptom state (PASS) or minimal clinically important difference (MCID) after revision lumbar fusion and assess whether this was influenced by the indication for revision. METHODS: We retrospectively identified all 1-3 level revision lumbar fusions at a single institution. Oswestry Disability Index (ODI) was collected at preoperative, three-month postoperative, and one-year postoperative time points. The MCID was calculated using a distribution-based method at each postoperative time point. PASS was set at the threshold of ≤ 22. RESULTS: We identified 197 patients: 56% with ASD, 28% with recurrent stenosis, and 15% with pseudarthrosis. The MCID for ODI was 10.05 and 10.23 at three months and one year, respectively. In total, 61% of patients with ASD, 52% of patients with nonunion, and 65% of patients with recurrent stenosis achieved our cohort-specific MCID at one year postoperatively with ASD (p = 0.78). At one year postoperatively, 33.8% of ASD patients, 47.8% of nonunion patients, and 37% of patients with recurrent stenosis achieved PASS without any difference between indication (p = 0.47). CONCLUSIONS: The majority of patients undergoing revision spine fusion experience significant postoperative improvements regardless of the indication for revision. However, a large proportion of these patients do not achieve the patient acceptable symptom state. While revision spine surgery may offer substantial benefits, these results underscore the need to manage patient expectations.

Radiology Reports Do Not Accurately Portray the Severity of Cervical Neural Foraminal Stenosis.

STUDY DESIGN: Retrospective study. OBJECTIVE: (1) To compare cervical magnetic resonance imaging (MRI) radiology reports to a validated grading system for cervical foraminal stenosis (FS) and (2) to evaluate whether the severity of cervical neural FS on MRI correlates to motor weakness or patient-reported outcomes. BACKGROUND: Radiology reports of cervical spine MRI are often reviewed to assess the degree of neural FS. However, research looking at the association between these reports and objective MRI findings, as well as clinical symptoms, is lacking. PATIENTS AND METHODS: We retrospectively identified all adult patients undergoing primary 1 or 2-level anterior cervical discectomy and fusion at a single academic center for an indication of cervical radiculopathy. Preoperative MRI was assessed for neural FS severity using the grading system described by Kim and colleagues for each level of fusion, as well as adjacent levels. Neural FS severity was recorded from diagnostic radiologist MRI reports. Motor weakness was defined as an examination grade <4/5 on the final preoperative encounter. Regression analysis was conducted to evaluate whether the degree of FS by either classification was related to patient-reported outcome measure severity. RESULTS: A total of 283 patients were included in the study, and 998 total levels were assessed. There were significant differences between the MRI grading system and the assessment by radio-logists ( P < 0.001). In levels with moderate stenosis, 28.9% were classified as having no stenosis by radiology. In levels with severe stenosis, 29.7% were classified as having mild-moderate stenosis or less. Motor weakness was found similarly often in levels of moderate or severe stenosis (6.9% and 9.2%, respectively). On regression analysis, no associations were found between baseline patient-reported outcome measures and stenosis severity assessed by radiologists or MRI grading systems. CONCLUSION: Radiology reports on the severity of cervical neural FS are not consistent with a validated MRI grading system. These radiology reports underestimated the severity of neural foraminal compression and may be inappropriate when used for clinical decision-making. LEVEL OF EVIDENCE: Level III.

The 5-item modified frailty index predicts spinal osteotomy outcomes better than age in adult spinal deformity patients: an ACS - NSQIP analysis.

PURPOSE: To evaluate the utility of 5-Item Modified Frailty Index (mFI-5) as compared to chronological age in predicting outcomes of spinal osteotomy in Adult Spinal Deformity (ASD) patients. METHODS: Using Current Procedural and Terminology (CPT) codes, the American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP) database was queried for adult patients undergoing spinal osteotomy from 2015 to 2019. Multivariate regression analysis was performed to evaluate the effect of baseline frailty status, measured by mFI-5 score, and chronological age on postoperative outcomes. Receiver-operating characteristic (ROC) curve analysis was performed to analyze the discriminative performance of age versus mFI-5. RESULTS: A total of 1,789 spinal osteotomy patients (median age 62 years) were included in the analysis. Among the patients assessed, 38.5% (n = 689) were pre-frail, 14.6% frail (n = 262), and 2.2% (n = 39) severely frail using the mFI-5. Based on the multivariate analysis, increasing frailty tier was associated with worsening outcomes, and higher odds ratios (OR) for poor outcomes were found for increasing frailty tiers as compared to age. Severe frailty was associated with the worst outcomes, e.g., unplanned readmission (OR 9.618, [95% CI 4.054-22.818], p < 0.001) and major complications (OR 5.172, [95% CI 2.271-11.783], p < 0.001). In the ROC curve analysis, mFI-5 score (AUC 0.838) demonstrated superior discriminative performance than age (AUC 0.601) for mortality. CONCLUSIONS: The mFI5 frailty score was found to be a better predictor than age of worse postoperative outcomes in ASD patients. Incorporating frailty in preoperative risk stratification is recommended in ASD surgery.

The impact of prior fragility fractures on long-term periprosthetic fracture risk following total knee arthroplasty.

The study found that patients undergoing total knee arthroplasty with prior fragility fracture had increased risk of subsequent fragility fracture and periprosthetic fracture within 8 years postoperatively when compared to those without a prior history. However, these patients were not at increased risk for all-cause revision within this period. PURPOSE: The aim of this study was to characterize the association of prior FFs on long-term risk of secondary fragility fracture (FF), periprosthetic fracture (PPF), and revision TKA. METHODS: Patients at least 50 years of age who underwent elective TKA were identified in the PearlDiver Database. Patients were stratified based on whether they sustained a FF within 3 years prior to TKA (7410 patients) or not (712,954 patients). Demographics and comorbidities were collected. Kaplan Meier analysis was used to observe the cumulative incidence of all-cause revision, PPF, and secondary FF within 8 years of TKA. Cox Proportional hazard ratio analysis was used to statistically compare the risk. RESULTS: In total, 1.0% of patients had a FF within three years of TKA. Of these patients, only 22.6% and 10.9% had a coded diagnosis of osteoporosis and osteopenia, respectively, at time of TKA. The 8-year cumulative incidence of secondary FF and periprosthetic fracture was significantly higher in those with a prior FF (27.5% secondary FF and 1.9% PPF) when compared to those without (9.1% secondary FF and 0.7% PPF). After adjusting for covariates, patients with a recent FF had significantly higher risks of secondary FF (HR 2.73; p < 0.001) and periprosthetic fracture (HR 1.86; p < 0.001) than those without a recent FF. CONCLUSIONS: Recent FF before TKA is associated with increased risk for additional FF and PPF within 8 years following TKA. Surgeons should ensure appropriate management of fragility fracture is undertaken prior to TKA to minimize fracture risk, and if not, be vigilant to identify patients with prior FF or other bone health risk factors who may have undocumented osteoporosis.

Racial disparities in readmission rates following surgical treatment of pediatric developmental dysplasia of the hip.

PURPOSE: Across orthopedic subspecialties, significant racial disparities have been identified with regard to postoperative outcomes. Despite these findings among adult patients, the literature assessing these disparities within pediatric orthopedics is limited. The purpose of this study was to determine the independent predictors for unplanned readmission following surgical treatment of developmental dysplasia of the hip. METHODS: Pediatric patients undergoing hip dysplasia surgery from 2012 to 2019 were identified in the National Surgical Quality Improvement Program-Pediatric database. Two patient groups were defined: patients who had unplanned hospital readmission within 30 days of surgery and patients who were not readmitted. Clinical characteristics assessed included gender, race, and American Society of Anesthesiologists (ASA) class. Risk factors for complications were assessed using bivariate and multivariate analysis. RESULTS: Of 6561 pediatric patients undergoing surgical treatment for hip dysplasia, 540 (8.2%) had unplanned readmission. On bivariate analysis, non-white race (Black, Asian, Hispanic, American Indian, and Native Hawaiian), an ASA class of III, IV, or V, pulmonary, renal, neurological, and gastrointestinal comorbidities, as well as immune disease, steroid use, and nutritional support were significantly associated with unplanned readmission (p < 0.05 for all). After controlling for confounding variables on multivariate analysis, non-white race (OR 1.46; p = 0.042) and ASA class of III-V (OR 2.21; p = 0.002) were found to be independent predictors for readmission. CONCLUSION: Clinicians should be advised of the increased readmission rates observed in non-white patients and those of higher ASA scores. Further work is needed to combat existing disparities within pediatric orthopedics.

Impact of COVID-19 on Spinal Diagnosis and Procedural Volume in the United States.

STUDY DESIGN: Retrospective analysis of a national database. OBJECTIVES: COVID-19 resulted in the widespread shifting of hospital resources to handle surging COVID-19 cases resulting in the postponement of surgeries, including numerous spine procedures. This study aimed to quantify the impact that COVID-19 had on the number of treated spinal conditions and diagnoses during the pandemic. METHODS: Using CPT and ICD-10 codes, TriNetX, a national database, was utilized to quantify spine procedures and diagnoses in patients >18 years of age. The period of March 2020-May 2021 was compared to a reference pre-pandemic period of March 2018-May 2019. Each time period was then stratified into four seasons of the year, and the mean average number of procedures per healthcare organization was compared. RESULTS: In total, 524,394 patient encounters from 53 healthcare organizations were included in the analysis. There were significant decreases in spine procedures and diagnoses during March-May 2020 compared to pre-pandemic levels. Measurable differences were noted for spine procedures during the winter of 2020-2021, including a decrease in lumbar laminectomy and anterior cervical arthrodesis. Comparing the pandemic period to the pre-pandemic period showed significant reductions in most spine procedures and treated diagnoses; however, there was an increase in open repair of thoracic fractures during this period. CONCLUSIONS: COVID-19 resulted in a widespread decrease in spinal diagnosis and treated conditions. An inverse relationship was observed between new COVID-19 cases and spine procedural volume. Recent increases in procedural volume from pre-pandemic levels are promising signs that the spine surgery community has narrowed the gap in unmet care produced by the pandemic.

Race Is Associated With Risk of Salvage Procedures and Postoperative Complications After Hip Procedures in Children With Cerebral Palsy.

BACKGROUND: Despite the many surgical interventions available for spastic hip dysplasia in children with cerebral palsy, a radical salvage hip procedure may still ultimately be required. The purpose of this study was to assess whether race is an independent risk factor for patients with cerebral palsy to undergo a salvage hip procedure or experience postoperative complications for hip dysplasia treatment. METHODS: This is a retrospective cohort analysis utilizing the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric database from 2012 to 2019. International Classification of Diseases, 9th and 10th Revisions, Clinical Modifications (ICD-9-CM, ICD-10-CM), and current procedural terminology (CPT) codes were used to identify patients with cerebral palsy undergoing hip procedures for hip dysplasia and to stratify patients into salvage or reconstructive surgeries. RESULTS: There was a total of 3906 patients with cerebral palsy between the ages of 2 and 18 years undergoing a procedure for hip dysplasia, including 1995 (51.1%) White patients, 768 (19.7%) Black patients, and 1143 (29.3%) patients from other races. Both Black ( P =0.044) and White ( P =0.046) races were significantly associated with undergoing a salvage versus a reconstructive hip procedure, with Black patients having an increased risk compared to White patients [adjusted odds ratio (OR) 1.77, confidence interval (CI) 1.02-3.07]. Only Black patients were found to have an increased risk of any postoperative complication compared to White patients, with an adjusted OR of 1.26 (CI 1.02-1.56; P =0.033). Both White ( P =0.017) and black ( P =0.004) races were found to be significantly associated with medical complications, with Black patients having an increased risk (adjusted OR 1.43, CI 1.12-1.84) compared to White patients. There were no significant findings between the race and risk of surgical site complications, unplanned readmissions, or reoperations. CONCLUSION: This study demonstrates that patient race is an independent association for the risk of pediatric patients with cerebral palsy to both undergo a salvage hip procedure and to experience postoperative medical complications, with Black patients having an increased risk compared to White. LEVEL OF EVIDENCE: Level III Retrospective Cohort Study.

Association of baseline frailty status and age with outcomes in patients undergoing intracranial meningioma surgery: Results of a nationwide analysis of 5818 patients from the National Surgical Quality Improvement Program (NSQIP) 2015-2019.

PURPOSE: The objective of this study was to compare the effect of frailty, as measured by the 5-factor modified frailty index (mFI-5), with that of age on postoperative outcomes of patients undergoing surgery for intracranial meningiomas, using data from a large national registry. METHODS: The National Surgical Quality Improvement Program (NSQIP) database (2015-2019) was queried to analyze data from patients undergoing intracranial meningioma resection (N = 5,818). Univariate and multivariate analyses of age and mFI-5 score were performed for 30-day mortality, major complications, unplanned reoperation, unplanned readmission, extended hospital length of stay (eLOS), and discharge to a non-home destination. RESULTS: Both univariate and multivariate analyses (adjusted for sex, body mass index, transfer status, smoking, and operative time) demonstrated that mFI-5 and age were significant predictors of adverse postoperative outcomes in patients with intracranial meningioma. However, based on odds ratios (OR) and effect sizes, increasing frailty tiers were better predictors than age of adverse outcomes. Severely frail patients showed highest effects sizes for all postoperative outcome variables [OR 11.17 (95% CI 3.45-36.19), p<0.001 for mortality; OR 4.15 (95% CI 2.46-6.99), p<0.001 for major complications; OR 4.37 (95% CI 2.68-7.12), p<0.001 for unplanned readmission; OR 2.31 (95% CI 1.17-4.55), p<0.001 for unplanned reoperation; OR 4.28 (95% CI 2.74-6.68), p<0.001 for eLOS; and OR 9.34 (95% CI 6.03-14.47, p<0.001) for discharge other than home. CONCLUSION: In this national database study, baseline frailty status was a better independent predictor for worse postoperative outcomes than age in patients with intracranial meningioma.

Frailty Status Is a More Robust Predictor Than Age of Spinal Tumor Surgery Outcomes: A NSQIP Analysis of 4,662 Patients.

OBJECTIVE: The present study aimed to evaluate the effect of baseline frailty status (as measured by modified frailty index-5 [mFI-5]) versus age on postoperative outcomes of patients undergoing surgery for spinal tumors using data from a large national registry. METHODS: The National Surgical Quality Improvement Program database was used to collect spinal tumor resection patients' data from 2015 to 2019 (n = 4,662). Univariate and multivariate analyses for age and mFI-5 were performed for the following outcomes: 30-day mortality, major complications, unplanned reoperation, unplanned readmission, hospital length of stay (LOS), and discharge to a nonhome destination. Receiver operating characteristic (ROC) curve analysis was used to evaluate the discriminative performance of age versus mFI-5. RESULTS: Both univariate and multivariate analyses demonstrated that mFI-5 was a more robust predictor of worse postoperative outcomes as compared to age. Furthermore, based on categorical analysis of frailty tiers, increasing frailty was significantly associated with increased risk of adverse outcomes. 'Severely frail' patients were found to have the highest risk, with odds ratio 16.4 (95% confidence interval [CI],11.21-35.44) for 30-day mortality, 3.02 (95% CI, 1.97-4.56) for major complications, and 2.94 (95% CI, 2.32-4.21) for LOS. In ROC curve analysis, mFI-5 score (area under the curve [AUC] = 0.743) achieved superior discrimination compared to age (AUC = 0.594) for mortality. CONCLUSION: Increasing frailty, as measured by mFI-5, is a more robust predictor as compared to age, for poor postoperative outcomes in spinal tumor surgery patients. The mFI-5 may be clinically used for preoperative risk stratification of spinal tumor patients.

Nationwide analysis of plastic and reconstructive procedural volume in the United States during the COVID-19 pandemic.

INTRODUCTION: This study aims to define the impact of the novel Coronavirus Disease 2019 (COVID-19) pandemic on the volume of common plastic and reconstructive procedures in the United States. METHODS: TrinetX is a national, federated database that was utilized in surveying plastic and reconstructive procedural volumes among 53 Healthcare organizations (HCO) between March 2018 and May 2021. This timeframe was divided into pre-pandemic (March 2018 to February 2020) and pandemic periods (March 2020 to May 2021). Each period was then sub-divided into four seasons of the year and the mean monthly procedural volume per HCO was compared. A student's t-tests comparing pre-pandemic and pandemic seasonal mean procedural volumes were used for statistical analysis. RESULTS: A total of 366,032 patient encounters among 53 HCO were included. The average seasonal volume per HCO of all procedures reduced from 872.11 procedures during pre-pandemic seasons to 827.36 during pandemic seasons. Spring 2020 vol declined for most procedures as 15 of 24 (63%) assessed procedure categories experienced statistically significant decreases. Spring 2021 experienced rebounds with 15 of 24 (63%) assessed procedures showing statistically significant increases. CONCLUSION: During the pandemic period, the average procedural volume per HCO of 14 procedure categories was significantly less than the pre-pandemic average procedural volume. Overall, an inverse relationship was observed between novel COVID-19 cases and plastic and reconstructive surgery procedure volumes in the United States.