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.

One year patient reported outcomes after single-level lumbar fusion at orthopedic specialty hospital compared to tertiary referral center.

BACKGROUND CONTEXT: Lumbar spinal fusion is an increasingly common operation to treat symptoms related to degenerative disorders of the spine including radiculopathy and pain. As the volume of spine surgeries grows, it is becoming increasingly common for procedures to take place in nontertiary care centers, including orthopaedic specialty hospitals (OSH). While previous research demonstrates that surgical outcomes at an OSH are noninferior to those at a tertiary referral center (TRC), the implications of this difference on patient-reported outcome measures (PROMs) have not been sufficiently assessed. PURPOSE: The objectives of this study were (1) to determine if changes in patient reported outcome measures (PROMs) after elective lumbar spinal fusion surgery differ between patients who undergo surgery at an orthopedic specialty hospital (OSH) and those who undergo surgery at a tertiary referral center (TRC) and (2) to characterize differences in short-term outcomes between hospitals. STUDY DESIGN: Retrospective cohort study. PATIENT SAMPLE: Adult patients (≥18 years old) who underwent primary, elective single-level posterior lumbar decompression and fusion between January 2014 and December 2021 at a tertiary referral center or an orthopaedic specialty hospital. OUTCOME MEASURES: PROMs: Oswestry Disability Index (ODI), Short-form 12 (SF12) Mental Component Summary (MCS); SF12 Physical Component Summary (PCS); Visual Analogue Back and Leg (VAS Back/Leg) METHODS: PROMs were collected preoperatively, 6 months after surgery, and 1 year after surgery. Six-month and 1-year delta PROM values were calculated by subtracting the preoperative PROM score from the 6-month or 1-year score, respectively. Multivariable linear regression analyses were conducted to assess the independent effect of hospital location on postoperative PROM scores. RESULTS: A total of 288 patients were identified as part of the study cohort including 205 patients who underwent surgery at the tertiary hospital and 83 patients who underwent surgery at the OSH. OSH patients had shorter length of stay (1.57±0.72 vs. 3.28±1.32, p<.001), however there was no difference in discharge disposition or 90-day readmission rates between hospitals (p>.05). At 6 months, having surgery at the specialty hospital was associated with higher PCS (estimate=2.96, confidence interval: 0.21-5.71, p=.035). At 1-year postoperatively, the location of surgery no longer demonstrated significant associations with PROM scores. Preoperative PROM scores demonstrated significant associations with 6-month and 1-year scores for each PROM (p<.05) except VAS leg at 6 months postoperatively. CONCLUSION: To our knowledge, this is one of the largest studies investigating PROMs at OSH versus TRCs for single-level lumbar fusions. We demonstrated that at 1-year follow-up, there is not a significant difference in PROM improvement between patients who undergo surgery at a TRC and patients who do so at an OSH.

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.

Opioid Prescription Trends Among Orthopaedic, Primary Care, and Pain Management Providers in Spine Surgery Patients.

OBJECTIVE: To determine prescription trends across specialties in the perioperative care of patients undergoing spine surgery from 2018 to 2021. SUMMARY OF BACKGROUND DATA: A range of measures, including implementation of state prescription drug monitoring programs, have been instituted to combat the opioid epidemic. Considering the continued presence of opioids for spine-related pain management, a better understanding of the patterns of opioid prescription practices may be important for future intervention. METHODS: All patients aged 18 years and older who underwent elective posterior lumbar decompression and fusion, transforaminal lumbar interbody fusion, and anterior cervical diskectomy and fusion from 2018 to 2021 were retrospectively identified. Patient demographics and surgical characteristics were collected through a Structured Query Language search and manual chart review. Opioid prescription data were collected through Pennsylvania's Prescription Drug Monitoring Program (PDMP) database and grouped into the following prescriber categories: primary care, pain management, physiatry, and orthopaedic surgery. RESULTS: Of the 1,062 patients, 302 (28.4%) underwent anterior cervical diskectomy and fusion, 345 (32.4%) underwent posterior lumbar decompression and fusion, and 415 (39.1%) underwent transforaminal lumbar interbody fusion. From 2018 to 2021, there were no significant differences in total opioid prescriptions from orthopaedic surgery (P = 0.892), primary care (P = 0.571), pain management (P = 0.687), or physiatry (P = 0.391) providers. Pain management providers prescribed the most opioids between 1 year and 2 months preoperatively (P = 0.003), between 2 months and 1 year postoperatively (P = 0.018), and overall (P < 0.001). CONCLUSION: Despite increasing national awareness of the opioid epidemic and the establishment of statewide prescription drug monitoring programs, prescription rates have not changed markedly in spine patients. Pain management and primary care physicians prescribe opioids at a higher rate in the chronic periods before and after surgery, likely in part because of longitudinal relationships with these patients. LEVEL OF EVIDENCE: III. STUDY DESIGN: Retrospective Cohort Study.

An evaluation of fusion status following lumbar fusion surgery utilizing multi-planar computed tomography.

PURPOSE: To report the rate of fusion in a sample of patients undergoing lumbar fusion surgery and assess interrater reliability of computed tomography (CT)-based parameters for the assessment of fusion. METHODS: All adult patients who underwent lumbar fusion surgery from 2017 to 2021 were retrospectively identified. Patient demographics and surgical characteristics were collected through chart review of the electronic medical records. CT scans were reviewed independently by two attending spine surgeons and two spine fellows. Fusion was defined as evidence of bone bridging in any one of (1) posterolateral gutters, (2) facets, or (3) interbody (when applicable) on any CT views. Evidence of screw haloing was indicative of nonunion. Interrater reliability was determined using cohen's kappa. Afterwards, a consensus agreement for each component of fusion was reached between participants. RESULTS: The overall fusion rate among all procedures was 63/69 (91.3%). Overall 22/25 (88.0%) TLIF, 16/19 (84.2%) PLDF, 3/3 (100%) LLIF, and 22/22 (100%) circumferential fusions experienced a successful fusion. Interrater reliability was good for interbody fusion (k = 0.734) and moderate for all other measures (k = 0.561 for posterolateral fusion; k = 0.471 for facet fusion; k = 0.458 for screw haloing). Overall, interrater reliability as to whether a patient had a fusion or nonunion was moderate (k = 0.510). CONCLUSION: There was only moderate interrater reliability across most radiographic measures used in assessing lumbar fusion status. Reliability was highest when evaluating the presence of interbody fusion. The majority of fusions occurred across the facet joints.

Impact of the Prognostic Nutritional Index on Outcomes in Native Spine Infection.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The objective of this study was to determine if baseline prognostic nutritional index (PNI) score could be used to predict outcomes in patients with native spine infections, including the need for operative intervention. SUMMARY OF BACKGROUND DATA: Nutritional status is an important, potentially modifiable risk factor, to consider in the native spine population. The prognostic nutritional index (PNI) score is a tool that has demonstrated utility as a marker of preoperative nutritional status in patients undergoing surgery, however it has not yet been studied in the context of native spine infection. METHODS: Adult patients (≥18 y) with a diagnosis of spine infection from 2017-2022 were retrospectively identified. Native spine infection was defined as a diagnosis of spinal infection in the absence of prior spine surgery within 3 months of diagnosis. PNI was calculated using the equation: PNI = 10 * serum albumin (g/dL) + 0.005 Total Lymphocyte Count (/µL. Patients were stratified into high or low PNI groups based on their PNI being above or below the average, respectively. RESULTS: There were 45 patients in the low PNI group and 56 patients in the high PNI group. Patients in the low PNI group were more likely to require surgery (P=0.046), had more levels decompressed (P=0.012), and were more likely to undergo two or more irrigation & debridement procedures (P=0.016). Patients in the low PNI group were also less likely to be discharged home (P=0.016). There was no difference in length of stay, inpatient complications, 90-day readmissions, 90-day ED visits, or 1-year reoperations between groups. CONCLUSION: While post-admission outcomes and inpatient complications were similar across PNI groups, PNI on admission provides useful insight into the severity of infection and predicts the need for operative intervention in patients presenting with native spine infection.

An Update in Complication Rates Associated With Anterior Lumbar Surgery: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic Review and meta-analysis. OBJECTIVE: To conduct an updated systematic review and meta-analysis of complications associated with different anterior fusion techniques/approaches and adjuvant resources (i.e., computed tomography angiography (CTA), rhBMP-2, and access surgeons). METHODS: A systematic review was conducted from 1/1/2014-4/1/2024 for studies evaluating the incidence of complications associated with anterior lumbar procedures. Comparisons of complications were made between surgical approach, use of CTA, rhBMP-2, and access surgeons. Meta-analyses were conducted using a generalized linear mixed model. RESULTS: 54 studies were included in the final analysis with 8066 patients and an average follow-up of 31.2 months. The overall complication rate associated with anterior lumbar surgery was 13.1%, including an intraoperative complication rate of 3.8%, postoperative complication rate of 7.4%, infection rate of 1.5%, and reoperation rate of 1.7%. Forest plot analysis showed no significant difference in overall complication rates between open and mini-open techniques, although mini-open techniques were associated with lower overall reoperation rates. The use of CTA was associated with an increase in intraoperative and overall complications, and the use of an access surgeon was associated with a decreased risk of reoperation. The use of rhBMP-2 was not associated with overall complication risk. CONCLUSIONS: While anterior lumbar surgery provides numerous benefits, surgeons and patients alike should be aware of the complication and safety profile prior to surgery. High quality studies are warranted to help elucidate the true benefit of certain techniques and adjuvant resources in reducing complications.

Factors Related to Clinical Performance in Spine Surgery Fellowship: Can We Predict Success.

INTRODUCTION: The factors most important in the spine fellowship match may not ultimately correlate with quality of performance during fellowship. This study examined the spine fellow applicant metrics correlated with high application rank compared with the metrics associated with the strongest clinical performance during fellowship. METHODS: Spine fellow applications at three academic institutions were retrieved from the San Francisco Match database (first available to 2021) and deidentified for application review. Application metrics pertaining to research, academics, education, extracurriculars, leadership, examinations, career interests, and letter of recommendations were extracted. Attending spine surgeons involved in spine fellow selection at their institutions were sent a survey to rank (1) fellow applicants based on their perceived candidacy and (2) the strength of performance of their previous fellows. Pearson correlation assessed the associations of application metrics with theoretical fellow rank and actual performance. RESULTS: A total of 37 spine fellow applications were included (Institution A: 15, Institution B: 12, Institution C: 10), rated by 14 spine surgeons (Institution A: 6, Institution B: 4, Institution C: 4). Theoretical fellow rank demonstrated a moderate positive association with overall research, residency program rank, recommendation writer H-index, US Medical Licensing Examination (USMLE) scores, and journal reviewer positions. Actual fellow performance demonstrated a moderate positive association with residency program rank, recommendation writer H-index, USMLE scores, and journal reviewer positions. Linear regressions identified journal reviewer positions (ß = 1.73, P = 0.002), Step 1 (ß = 0.09, P = 0.010) and Step 3 (ß = 0.10, P = 0.002) scores, recommendation writer H-index (ß = 0.06, P = 0.029, and ß = 0.07, P = 0.006), and overall research (ß = 0.01, P = 0.005) as predictors of theoretical rank. Recommendation writer H-index (ß = 0.21, P = 0.030) and Alpha Omega Alpha achievement (ß = 6.88, P = 0.021) predicted actual performance. CONCLUSION: Residency program reputation, USMLE scores, and a recommendation from an established spine surgeon were important in application review and performance during fellowship. Research productivity, although important during application review, was not predictive of fellow performance. LEVEL OF EVIDENCE: III. STUDY DESIGN: Cohort Study.

Physical and Psychological Impact of Scar Cosmesis After Cervical Spine Fusion Surgery.

INTRODUCTION: Patients' and surgeons' perceptions of cutaneous scarring can vary, causing unpleasant physical and psychological outcomes. This study aims to bridge the current scientific literature gap and understand the impact of patient-perceived scar cosmesis after anterior and posterior cervical spine surgery. METHODS: Retrospective review of patients ≥18 years old who underwent anterior or posterior cervical spine surgery from 2017 to 2022 at a large, urban academic group. To select patients with adequate time for surgical scar maturation, only patients who were greater than 6 months postsurgery were included. The Scar Questionaire Survey (SCAR-Q) survey, a surgical scar assessment tool, was administered to patients to assess patient perceptions of scar symptomatology, appearance, and psychosocial impact. Scores range from 0 to 100, with 100 as the best outcome. An additional 5-item Likert scale question was administered to assess overall surgical satisfaction. RESULTS: All 854 respondents who completed the survey were stratified into 2 groups "Unsatisfied vs. Satisfied." Patients who were "unsatisfied" with their surgery had the lowest outcome scores for SCAR-Q appearance, symptom, and psychosocial scores than those who were "Satisfied" (P < 0.001). Females had significantly "higher/more favorable" responses for SCAR-Q Appearance (77.5 vs. 82.8 P < 0.001) and Psychosocial (87.4 vs. 94.3 P < 0.001) scores compared to males. Regression analysis performed for each component score showed that increases in all 3 component scores were significant in patients in the satisfied group. CONCLUSIONS: Our study demonstrates that cervical spine surgery patients unsatisfied with their surgical outcome have lower scar-related scores, highlighting the impact of cosmetic closure and appearance.

Which North American spine society disc herniation morphology descriptors are most associated with improvements in clinical outcomes after microdiscectomy?

Background: The North American Spine Society (NASS) assembled the first ever comprehensive naming system for describing lumbar disc disease, including lumbar disc herniation. The objectives of this study were (1) to determine which NASS descriptors are most predictive of independent patient-reported outcomes after microdiscectomy and (2) to identify the inter-rater reliability of each NASS descriptor. Methods: Adult patients (≥18 years) who underwent a lumbar microdiscectomy from 2014-2021 were retrospectively identified. Patient-reported outcome measures (PROMs) were collected at preoperative, 3-month, and 1-year postoperative time points. Lumbar disc herniations were evaluated and classified on preoperative MRI using the NASS lumbar disc nomenclature specific to disc herniation. Results: About 213 microdiscectomy patients were included in the final analysis. Herniation descriptors exhibiting the greatest reliability included sequestration status (κ=0.83), axial disc herniation area (κ=0.83), and laterality (κ=0.83). The descriptor with the lowest inter-rater reliability was direction of migration (κ=0.53). At 3 months, a sequestered herniation was associated with lower odds of achieving the minimal clinically important difference (MCID) for ODI (p=.004) and MCS (p=.032). At 12 months, a similar trend was observed for Oswestry Disability Index (ODI) MCID achievement (p=.001). At 3 months, a herniation with larger axial area was a predictor of MCID achievement in ODI (p=.004) and the mental component summary (MCS) (p=.009). Neither association persisted at 12 months; however, larger axial disc herniation area was able to predict MCID achievement in the Visual Analogue Scale (VAS) leg (p=.031) at 12 months. Conclusions: The utility of the NASS nomenclature system in predicting postoperative outcomes after microdiscectomy has yet to be studied. We showed that sequestration status and disc area are both reliable and able to predict the odds of achieving MCID in certain clinical outcomes at 3 months and 12 months after surgery. Hence, preoperative imaging analysis of lumbar disc herniations may be useful in accurately setting patient expectations.

Preoperative Radiographic Predictors of Subsequent Fusion after Lumbar Decompression Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The purpose of this study is to determine which demographic, surgical, and radiographic preoperative characteristics are most associated with the need for subsequent fusion after decompression lumbar spinal surgery. SUMMARY OF BACKGROUND DATA: There is a relatively high rate of the need for repeat decompression or fusion after an index decompression procedure for degenerative spine disease. Nevertheless, there is a dearth of literature identifying risk factors for lumbar fusion following decompression surgery. METHODS: Patients 18 years or older receiving a primary lumbar decompression surgery within the levels of L3-S1 between 2011 and 2020 were identified. All patients had preoperative radiographs and 2 years of follow-up data. Chart review was performed for surgical characteristics and demographics. The sagittal parameters included lumbar lordosis (LL), segmental lordosis (SL), anterior disc height (aDH), posterior disk height (pDH), sacral slope (SS), and pelvic tilt (PT). Pelvic incidence (PI=PT+SS) and pelvic incidence minus lumbar lordosis (PI-LL) were calculated. In addition, the Roussouly classification was determined for each patient. Bivariant and multivariant analyses were performed. RESULTS: Of the 363 patients identified in this study, 96 patients had a fusion after their index decompression surgery. Multivariable analysis identified involvement of L4-L5 level in the decompression (odds ratio (OR)=1.83 (1.09-3.14), P=0.026), increased L5-S1 segmental lordosis (OR=1.08 (1.03-1.13), P=0.001), decreased SS (OR=0.96 (0.93-0.99), P=0.023), and decreased endplate obliquity (OR=0.88 (0.77-0.99), P=0.040) as significant independent predictors of fusion after decompression surgery. CONCLUSIONS: This is one of the first studies to assess preoperative sagittal parameters in conjunction with demographic variables to determine predictors of the need for fusion after index decompression. We demonstrated that decompression at L4-L5, greater L5-S1 segmental lordosis, decreased sacral slope, and decreased endplate obliquity were associated with higher rates of fusion after decompression surgery.

The Impact of the Preoperative Mental Health Component Summary (MCS) Score on Short-term Outcomes after Lumbar Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The purpose of this study is to characterize the relationship between preoperative MCS and surgical outcomes after lumbar spine surgery including inpatient complications, length of stay, readmissions, and reoperations. SUMMARY OF BACKGROUND DATA: As the prevalence of mental health disorders in the United States increases, it is important to identify risks associated with poor mental health status in the surgical spine patient. The mental health component summary (MCS) of the Short Form-12 has been used extensively as an indication of a patient's mental health status and psychological well-being. METHODS: Adult patients older than or equal to 18 years who underwent primary one to three level lumbar fusion surgery at our academic medical institution from 2017 to 2021 were retrospectively identified. Preoperative MCS score was used to analyze outcomes in patients based on a cutoff (<45.6). A score >45.6 indicated better preoperative mental health and a score <45.6 indicated worse preoperative mental health. RESULTS: Patients with lower preoperative MCS scores had longer hospital stays (3.86 + 2.16 vs. 3.55 + 1.42 days, P=0.010) and were more likely to have inpatient renal complications (3.09% vs. 7.19%, P=0.006). Patients with lower preoperative MCS scores also had lower Activity Measure for Post-Acute Care (AM-PAC) scores (17.1 + 2.85 vs. 17.6 + 2.49, P=0.030). Ninety-day surgical readmissions, medical readmissions, and reoperations were not significantly different between groups (P>0.05). CONCLUSION: Our study suggests that patients with lower preoperative mental health scores (MCS < 45.6) were independently more likely to experience more renal complications and longer length of stay after primary lumbar fusion. Additionally, higher MCS scores may correlate with better postoperative mobility and daily activity scores. Nevertheless, long-term outcomes are not significantly different between patients of better or worse preoperative mental health.

Comparison of Length of Stay and Discharge Disposition after Short-Segment Lumbar Fusion Surgery at Tertiary Care and Non-Tertiary Care Hospitals: A Propensity Score Matched Analysis.

STUDY DESIGN: A retrospective study. OBJECTIVE: To compare the perioperative and postoperative outcomes among lumbar fusion patients treated at an orthopaedic specialty hospital (OSH), a hybrid community hospital (HCH), and a conventional community hospital in comparison to a tertiary care hospital (TCH). SUMMARY OF BACKGROUND DATA: In spine surgery, strategies to reduce length of stay (LOS) include a myriad of pre-, intra-, and postoperative strategies that require a multidisciplinary infrastructure. The sum of these efforts has led to the creation of orthopedic specialty hospitals and protocols that have been adopted by community hospitals as well. There is a notable lack of information regarding the results of these efforts across different healthcare institution models. METHODS: This was a retrospective study of patients undergoing elective one or two-level lumbar fusion between 2017 and 2022 at a large urban TCH, an OSH, a HCH, and a conventional CH. Data was collected on patient characteristics, demographics, comorbidities, BMI, smoking status, surgical type, surgical levels, surgery duration, hospital length of stay, readmissions, reoperations, and discharge status within a year. Patients across the four surgical settings were matched based on age, BMI, CCI, type of procedure, and number of levels fused. RESULTS: A total of 1435 patients met the inclusion criteria. Length of hospital stay was significantly longer at TCH compared to OSH, HCH, and CH by an average of 1-2 days (P<0.001). 90-day readmissions were higher at TCH compared to OSH (P=0.001). TCH patients also were less likely to be discharged home than OSH and HCH patients (P=0.001 and P=0.016, respectively). No significant differences were noted in 1-year reoperation rates across all hospital models. CONCLUSION: Shorter lengths of stays and more home discharges at the orthopaedic specialty hospital and community hospital settings did not compromise surgical quality or postoperative outcomes.

The Impact of Outpatient Physical Therapy on Patient-Reported Outcomes After Lumbar Fusion: Perspective from A Bundled Care Dataset.

OBJECTIVE/BACKGROUND: As value-based care grows in popularity across the United States, more payers have turned toward bundled payment models for surgical procedures. Though episode costs in spine are highly variable, physical therapy (PT) has been identified as a driver of 90-day cost. The goal of this study is to assess the impact of postoperative PT on patient-reported outcomes and cost after lumbar fusion surgery using bundled insurance data. METHODS: Bundled payment information of lumbar fusion episodes-of-care (EOC) from 2019 to 2021 was reviewed at a single, urban, tertiary care center. EOC comprised a 210-day period surrounding the date of the procedure, beginning 30 days preoperatively and ending 180 days postoperatively. Patients were grouped into physical therapy (PT) and no physical therapy (no PT) groups based on the presence of PT claims. RESULTS: Bivariate analysis of surgical outcomes revealed similar overall complication rates (P = 0.413), 30-day readmissions (P = 0.366), and 90-day readmissions (P = 0.774). Patients who did not participate in postoperative PT had significantly better preoperative physical component score (PCS) (P = 0.003), 6-month postoperative PCS (P = 0.001), and 6-month ΔPCS (P = 0.026) compared with patients who participated in postoperative PT. At 1-year follow-up, patients who did not participate in PT had less leg pain (P = 0.041) than those who did participate in PT. CONCLUSIONS: Our study finds that PT after lumbar fusion is not associated with significant improvement in Oswestry Disability Index, PCS, mental component score, or visual analog scale pain scores. Additionally, the number of PT sessions a patient attends has no correlation with improvement in these outcomes.

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.

Postoperative opioid consumption patterns diverge between propensity matched patients undergoing traumatic and elective cervical spine fusion.

BACKGROUND CONTEXT: Prolonged opioid therapy following spine surgery is an ongoing postoperative concern. While prior studies have investigated postoperative opioid use patterns in the elective cervical surgery patient population, to our knowledge, opioid use patterns in patients undergoing surgery for traumatic cervical spine injuries have not been elucidated. PURPOSE: The purpose of this study was to compare opioid use and prescription patterns in the postoperative pain management of patients undergoing traumatic and elective cervical spine fusion surgery. STUDY DESIGN: Retrospective cohort study. PATIENT SAMPLE: Adult patients with traumatic cervical injuries who underwent primary anterior cervical discectomy and fusion (ACDF) or posterior cervical decompression and fusion (PCDF) during their initial hospital admission. The propensity matched, control group consisted of adult elective cervical fusion patients who underwent primary ACDF or PCDF. OUTCOME MEASURES: Demographic data, surgical characteristics, spinal disease diagnosis, location of cervical injury, procedure type, operative levels fused, and Prescription Drug Monitoring Program (PDMP) data. PDMP data included the number of opioid prescriptions filled, preoperative opioid use, postoperative opioid use, and use of perioperative benzodiazepines, muscle relaxants, or gabapentin. Opioid consumption data was collected in morphine milligram equivalents (MME) and standardized per day. METHODS: A 1:1 propensity match was performed to match traumatic injury patients undergoing cervical fusion surgery with elective cervical fusion patients. Traumatic injury patients were matched based on age, sex, CCI, procedure type, and cervical levels fused. Pre- and postoperative opioid, benzodiazepine, muscle relaxant, and gabapentin use were assessed for the traumatic injury and elective patients. T- or Mann-Whitney U tests were used to compare continuous data and Chi-Squared or Fisher's Exact were used to compare categorical data. Multivariate stepwise regression using MME per day 0 - 30 days following surgery as the dependent outcome was performed to further evaluate associations with postoperative opioid use. RESULTS: A total of 48 patients underwent fusion surgery for a traumatic cervical spine injury and 48 elective cervical fusion with complete PDMP data were assessed. Elective patients were found to fill more prescriptions (3.19 vs 0.65, p=.023) and take more morphine milligram equivalents (MME) per day (0.60 vs 0.04, p=.014) within 1 year prior to surgery in comparison to traumatic patients. Elective patients were also more likely to use opioids (29.2% vs 10.4%, p=.040) and take more MMEs per day (0.70 vs 0.05, p=.004) within 30 days prior to surgery. Within 30 days postoperatively, elective patients used opioids more frequently (89.6% vs 52.1%, p<.001) and took more MMEs per day (3.73 vs 1.71, p<.001) than traumatic injury patients. Multivariate stepwise regression demonstrated preoperative opioid use (Estimate: 1.87, p=.013) to be correlated with higher postoperative MME per day within 30 days of surgery. Surgery after traumatic injury was correlated with lower postoperative MME use per day within 30 days of surgery (Estimate: -1.63 p=.022). CONCLUSION: Cervical fusion patients with a history of traumatic spine injury consume fewer opioids in the early postoperative period in comparison to elective cervical fusion patients, however both cohorts consumed a similar amount after the initial 30-day postoperative period. Preoperative opioid use was also a risk factor for higher consumption in the short-term postoperative period. These results may aid physicians in further understanding patients' postoperative care needs based on presenting injury characteristics and highlights the need for enhanced follow-up care for traumatic cervical spine injury patients after fusion surgery.

Does Paraspinal Muscle Mass Predict Lumbar Lordosis before and after Decompression for Degenerative Spinal Stenosis?

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: The purpose of this study was to determine if muscle mass and quality of the lumbar paraspinal muscles was associated with improvements in lumbar lordosis and other sagittal parameters after isolated posterior lumbar decompression surgery for lumbar spinal stenosis. SUMMARY OF BACKGROUND DATA: Over time, either due to degenerative changes or other spinal conditions, individuals may develop sagittal imbalance. In patients with lumbar spinal stenosis, sagittal imbalance can further exacerbate symptoms of pain and radiculopathy. Sarcopenia of paraspinal muscles has been implicated in previous spine research as a variable with influence on surgical outcomes. METHODS: Sagittal parameters were measured on preoperative and postoperative lateral lumbar radiographs and included lumbar lordosis (LL), sacral slope (SS), and pelvic tilt (PT). Preoperative MRI images were evaluated at the base of the L4 vertebral body to assess muscles mass of the psoas muscle and paravertebral muscles (PVM) and Goutallier grade of the PVM. Patients were divided into 3 muscle size groups based on PVM normalized for body size (PVM/BMI): Group A (smallest), Group B, and Group C (largest). RESULTS: Patients in Group C had greater LL preoperatively (51.5° vs. 47.9° vs. 43.2, P=0.005) and postoperatively (52.2° vs. 48.9° vs. 45.7°, P=0.043). There was no significant difference in the ∆LL values between groups (P>0.05). Patients in Group C had larger SS preoperatively (35.2° vs. 32.1° vs. 30.0°, P=0.010) and postoperatively (36.1° vs. 33.0° vs. 31.7°, P=0.030). Regression analysis showed that PVM/BMI was a significant predictor of LL preoperatively (P=0.039) and postoperatively (P=0.031), as well as SS preoperatively (P=0.001) and postoperatively (P<0.001). CONCLUSION: Muscle mass of the paravertebral muscles significantly impacts lumbar lordosis and sacral slope in patients with lumbar spinal stenosis before and after posterior lumbar decompression. These findings highlight a need to address risk factors for poor muscle quality in patients with sagittal imbalance.

The impact of robotic assistance for lumbar fusion surgery on 90-day surgical outcomes and 1-year revisions.

Objectives: To evaluate the (1) 90-day surgical outcomes and (2) 1-year revision rate of robotic versus nonrobotic lumbar fusion surgery. Methods: Patients >18 years of age who underwent primary lumbar fusion surgery at our institution were identified and propensity-matched in a 1:1 fashion based on robotic assistance during surgery. Patient demographics, surgical characteristics, and surgical outcomes, including 90-day surgical complications and 1-year revisions, were collected. Multivariable regression analysis was performed. Significance was set to P < 0.05. Results: Four hundred and fifteen patients were identified as having robotic lumbar fusion and were matched to a control group. Bivariant analysis revealed no significant difference in total 90-day surgical complications (P = 0.193) or 1-year revisions (P = 0.178). The operative duration was longer in robotic surgery (287 + 123 vs. 205 + 88.3, P ≤ 0.001). Multivariable analysis revealed that robotic fusion was not a significant predictor of 90-day surgical complications (odds ratio [OR] = 0.76 [0.32-1.67], P = 0.499) or 1-year revisions (OR = 0.58 [0.28-1.18], P = 0.142). Other variables identified as the positive predictors of 1-year revisions included levels fused (OR = 1.26 [1.08-1.48], P = 0.004) and current smokers (OR = 3.51 [1.46-8.15], P = 0.004). Conclusion: Our study suggests that robotic-assisted and nonrobotic-assisted lumbar fusions are associated with a similar risk of 90-day surgical complications and 1-year revision rates; however, robotic surgery does increase time under anesthesia.

The Relationship Between Disc Herniation Morphology and Patient-Reported Outcomes after Microdiscectomy.

OBJECTIVE: Determine if herniation morphology based on the Michigan State University Classification is associated with differences in (1) patient-reported outcome measures (or (2) surgical outcomes after a microdiscectomy. METHODS: Adult patients undergoing single-level microdiscectomy between 2014 and 2021 were identified. Demographics and surgical characteristics were collected through a query search and manual chart review. The Michigan State University classification, which assesses disc herniation laterality (zone A was central, zone B/C was lateral) and degree of extrusion into the central canal (grade 1 was up to 50% of the distance to the intra-facet line, grade >1 was beyond this line), was identified on preoperative MRIs. patient-reported outcome measures were collected at preoperative, 3-month, and 1-year postoperative time points. RESULTS: Of 233 patients, 84 had zone A versus 149 zone B/C herniations while 76 had grade 1 disc extrusion and 157 had >1 grade. There was no difference in surgical outcomes between groups (P > 0.05). Patients with extrusion grade >1 were found to have lower Physical Component Score at baseline. On bivariate and multivariable logistic regression analysis, extrusion grade >1 was a significant independent predictor of greater improvement in Physical Component Score at three months (estimate = 7.957; CI: 4.443-11.471, P < 0.001), but not at 1 year. CONCLUSIONS: Although all patients were found to improve after microdiscectomy, patients with disc herniations extending further posteriorly reported lower preoperative physical function but experienced significantly greater improvement three months after surgery. However, improvement in Visual Analog Scale Leg and back, ODI, and MCS at three and twelve months was unrelated to laterality or depth of disc herniation.

In-hospital mortality trends after surgery for traumatic thoracolumbar injury: A national inpatient sample database study.

Introduction: Given the increasing incidence of traumatic thoracolumbar injuries in recent years, studies have sought to investigate potential risk factors for outcomes in these patients. Research question: The aim of this study was to investigate trends and risk factors for in-hospital mortality after fusion for traumatic thoracolumbar injury. Materials and methods: Patients undergoing thoracolumbar fusion after traumatic injury were queried from the National Inpatient Sample (NIS) from 2012 to 2017. Analysis was performed to identify risk factors for inpatient mortality after surgery. Results: Patients in 2017 were on average older (51.0 vs. 48.5, P = 0.004), had more admitting diagnoses (15.5 vs. 10.7, p < 0.001), were less likely to be White (75.8% vs. 81.2%, p = 0.006), were from a ZIP code with a higher median income quartile (Quartile 1: 31.4% vs. 28.6%, p = 0.011), and were more likely to have Medicare as a primary payer (22.9% vs. 30.1%, p < 0.001). Bivariate analysis of demographics and surgical characteristics demonstrated that patients in the in-hospital mortality group (n = 90) were older (70.2 vs. 49.6, p < 0.001), more likely to be male (74.4% vs. 62.8%, p = 0.031), had a great number of admitted diagnoses (21.3 vs. 12.7, p < 0.001), and were more likely to be insured by Medicare (70.0% vs. 27.0%, p < 0.001). Multivariate regression analysis found age (OR 1.06, p < 0.001) and Black race (OR 3.71, p = 0.007) were independently associated with in-hospital mortality. Conclusion: Our study of nationwide, traumatic thoracolumbar fusion procedures from 2012 to 2017 in the NIS database found older, black patients were at increased risk for in-hospital mortality after surgery.