Comparison of No Tap (two-step) and tapping robotic assisted cortical bone trajectory screw insertion.

Workflow for cortical bone trajectory (CBT) screws includes tapping line-to-line or under tapping by 1 mm. We describe a non-tapping, two-step workflow for CBT screw placement, and compare the safety profile and time savings to the Tap (three-step) workflow. Patients undergoing robotic assisted 1-3 level posterior fusion with CBT screws for degenerative conditions were identified and separated into either a No-Tap or Tap workflow. Number of total screws, screw-related complications, estimated blood loss, operative time, robotic time, and return to the operating room were collected and analyzed. There were 91 cases (458 screws) in the No-Tap and 88 cases (466 screws) in the Tap groups, with no difference in demographics, revision status, ASA grade, approach, number of levels fused or diagnosis between cohorts. Total robotic time was lower in the No-Tap (26.7 min) versus the Tap group (30.3 min, p = 0.053). There was no difference in the number of malpositioned screws identified intraoperatively (10 vs 6, p = 0.427), screws converted to freehand (3 vs 3, p = 0.699), or screws abandoned (3 vs 2, p = 1.000). No pedicle/pars fracture or fixation failure was seen in the No-Tap cohort and one in the Tap cohort (p = 1.00). No patients in either cohort were returned to OR for malpositioned screws. This study showed that the No-Tap screw insertion workflow for robot-assisted CBT reduces robotic time without increasing complications.

Intra-Operative Hypotension is an Important Modifiable Risk Factor for Major Complications in Spinal Fusion Surgery.

STUDY DESIGN: Retrospective observational cohort. OBJECTIVES: This study explores the impact of Intraoperative hypotension (IOH)on post-op complications for major thoracolumbar spine fusion procedures. SUMMARY OF BACKGROUND DATA: IOH with mean arterial pressure (MAP) < 65 mmHg is associated with post-op acute kidney injury (AKI) in general surgery. In spinal deformity surgery, IOH is a contributing factor to MEP changes and spinal cord dysfunction with deformity correction. METHODS: 539 thoracolumbar fusion cases, > 6 surgical levels and > 3 hours duration were identified. Anesthetic/surgical data included OR time, fluid volume, blood loss, blood product replacement and use of vasopressors. Arterial-line based MAP data was collected at 1 min intervals. Cummulative duration of MAP < 65 mmHg was recorded. IOH within the first hour of surgery vs. the entire case was determined. Post-op course and complications including SSI, GI complications, pulmonary complications, MI, DVT, PE, AKI and encephalopathy were noted. Cumulative complications were grouped as none, 1-2 complications, or >3 complications. RESULTS: There was a significant association between occurrence of complications and duration of IOH within the first hour of surgery (8.2 vs. 5.6 min, P<0.001) and across the entire procedure (28.1 vs. 19.3 min, P=0.008). This association persisted for individual major complications including SSI, acute respiratory failure, PE, ileus requiring NGT and post-operative cognitive dysfunction. Comparison of patients with 0 vs. 1-2 vs. 3 or more complications demonstrated that patients with 3 or more complications had a longer duration of IOH in the first hour of the surgery and that patients who had no complications received less vasopressor than patients who had 1-2 or 3 or more complications. CONCLUSION: This study identifies duration of IOH during the first hour of surgery as a previously unrecognized modifiable risk associated with major complications for multi-level lumbar fusion surgery.

Proximal Junctional Degeneration and Failure Modes: A Novel Classification and Clinical Implications.

STUDY DESIGN: Case-control study. OBJECTIVE: To introduce a classification system that will include the major types of degenerative changes and failures related to the proximal junction, and to determine the clinical course and characteristics for the different types of proximal junctional degeneration (PJD). SUMMARY OF BACKGROUND DATA: Proximal junctional kyphosis (PJK) and failures are well recognized after adult spinal fusion, however, a standardized classification is lacking. METHODS: The proposed system identified four different patterns of PJD: Type 1 (multi-level symmetrical collapse), Type 2 (Single adjacent level collapse), Type 3 (fracture) and Type 4 (spondylolisthesis). A single center database was reviewed from 2018 to 2021. Patients ≥18 years of age, who underwent posterior spinal fusion of ≥3 levels with an upper instrumented vertebral level between T8-L2, and a follow-up of ≥2 years were included. Radiographic measurements, revision surgery and time to revision were the primary outcomes. RESULTS: 150 patients were included with a mean age of 65.1 (±9.8) years and a mean follow-up of 3.2 (±1) years. 69 patients (46%) developed significant degenerative changes in the proximal junction, and were classified accordingly. 20 (13%) were Type 1, 17 (11%) were Type 2, 22 (15%) were Type 3 and 10 (7%) were Type 4. Type 3 had a significantly shorter time to revision with a mean of 0.9 (±0.9) years. Types 3 and 4 had greater preoperative sagittal vertical axis, and Types 1 and 3 had greater final follow-up lumbar lordosis. Bone density measured by Hounsfield units showed lower measurements for Type 3. Types 1 and 4 had lower rates of developing PJK. Type 1 had the lowest revision rate with 40% (types 2, 3 and 4 were 77%, 73% and 80%, respectively, P=0.045). CONCLUSION: This novel classification system defines different modes of degeneration and failures at the proximal junction, and future studies with larger sample sizes are needed for validation. LEVEL OF EVIDENCE: 3.

Measuring quality of recovery (QoR-15) after degenerative spinal surgery: A prospective observational study.

Introduction: The Quality of Recovery (QoR-15) score evaluates patient's recovery after surgery and anesthesia. There is a lack of studies focusing on the patients' quality of recovery in the early post-discharge phase after elective lumbar spine surgery. Research question: We aimed to identify the QoR-15 score in patients who underwent surgery for degenerative low back conditions. Furthermore, we aimed to identify the individual items of the QoR-15 that are crucial for the patients' quality of recovery. Material and methods: The study was conducted at a spine center in Denmark from December 2021 to September 2022. Data were collected, using a mobile health application, preoperatively and at 3 time points after hospital discharge. Descriptive analysis followed by within-subjects longitudinal repeated measures was conducted. The individual items of the QoR-15 score were explored using a heatmap. Results: Data from 46 patients were analysed. The mean QoR-15 sum score at baseline was 105.4 ± 18.3. The mean QoR-15 sum scores were 108.1 ± 19.2 on post-discharge day 1, 118.5 ± 17.4 on day 7, and 120.7 ± 20.9 on day 14. The mean QoR-15 score from day 1 to day 7 improved significantly. Eight of the 15 items influenced the overall QoR-15 score. Discussion and conclusion: This study applied the QoR-15 score in lumbar spine surgery patients. We identified specific items from the QoR-15 scale that are crucial to improving patients' recovery after hospital discharge. Further research is needed to identify specific needs in the post-discharge period in this group of patients.

Risk Factors for Medial Breach During Robotic-Assisted Cortical Bone Trajectory Screw Insertion.

OBJECTIVE: We describe the incidence of, and identify the risk factors for, a medial breach of the pedicle wall during robotic-assisted cortical bone trajectory (RA-CBT) screw insertion. METHODS: We analyzed a consecutive series of adult patients who underwent RA-CBT screw placement from January 2019 to July 2022. To assess the pedicle wall medial breach, postoperative computed tomography (CT) images were analyzed. Patient demographic data and screw data were compared between patients with and without a medial breach. The Hounsfield units (HUs) on the L1 midvertebral axial CT scan was used to evaluate bone quality. RESULTS: Of 784 CBT screws in 145 patients, 30 (3.8%) had a medial breach in 23 patients (15.9%). One screw was grade 2, and the others were grade 1. Patients with a medial breach had a lower HU value compared with the patients without a medial breach (123.3 vs. 150.5; P = 0.027). A medial breach was more common in the right than left side (5.5% vs. 2.0%; P = 0.014). More than one half of the screws with a medial breach were found in the upper instrumented vertebra (UIV) compared with the middle construct or lowest instrumented vertebra (6.7% vs. 1.3% vs. 2.7%; P = 0.003). Binary logistic regression showed that low HU values, right-sided screw placement, and UIV were associated with a medial breach. No patients returned to the operating room for screw malposition. No differences were found in the clinical outcomes between patients with and without a medial breach. CONCLUSIONS: The incidence of pedicle wall medial breach was 3.8% of RA-CBT screws in the postoperative CT images. A low HU value measured in the L1 axial image, right-sided screw placement, and UIV were associated with an increased risk of medial breach for RA-CBT screw placement.

The effect of myelography dye on bone density measurements utilizing Hounsfield units on CT.

OBJECTIVE: Hounsfield unit (HU) measurements of bone density on CT are increasingly used for preoperative planning in spine surgery. Postmyelogram CT is another common preoperative diagnostic study. However, there is no current literature evaluating whether HU measurements on CT are affected by the presence of myelography dye. The purpose of the current study was to determine if the presence of myelography dye affects HU measurements of bone density in CT studies. METHODS: Twenty-nine preoperative spine surgery patients who underwent both standard and postmyelography CT performed within 6 months of each other were identified. HU measurements were obtained from an elliptical region of interest using the available software on a standard PACS. Measurements were obtained on the axial cut at the midvertebral body on all lumbar vertebrae on three separate occasions and an average value was calculated for comparative analysis. A 6-week gap was used between measurements of the CT scans and the CT myelograms to diminish bias. RESULTS: The mean age of the cohort was 69 years and the average BMI was 32 kg/m2. Five patients were male and 24 were female. Six of the patients had instrumentation placed prior to the initial CT scan. The average HU measurements for CT levels L1-5 were 165, 171, 145, 154, and 225, respectively, whereas HU measurements for CT myelography of levels L1-5 were 168, 177, 148, 170, and 239, respectively. Strong correlations were noted between the HU measured on CT and CT myelography for L1 (r2 = 0.951), L2 (r2 = 0.966), L4 (r2 = 0.820), and L5 (r2 = 0.900), and moderate for L3 (r2 = 0.668). CONCLUSIONS: The presence of myelography dye had no clear effect on CT HU measurements of bone density. The results of this study support the use of CT myelograms for bone density assessment in the absence of standard CT images.

Staged circumferential lumbar fusions have less intraoperative complications and shorter operative time with no difference in 30-, 90-, and 1-year complications: a propensity-matched cohort analysis of 190 patients.

BACKGROUND CONTEXT: Circumferential lumbar fusions (cLFs) are becoming more common with increasing and more minimally invasive anterior access techniques. Staging allows reassessment of indirect decompression and alignment prior to the posterior approach, and optimization of OR time management. Safety of staging has been well documented in deformity surgery but has yet to be delineated in less extensive, degenerative cLFs. PURPOSE: The purpose of this study is to compare perioperative complications and outcomes between staged versus single-anesthetic circumferential fusions in the lumbar spine. STUDY DESIGN: Propensity-matched comparative observational cohort. PATIENT SAMPLE: Patients who underwent cLFs for lumbar degenerative disease. OUTCOME MEASURES: In-hospital, 30-day, 90-day, and 1-year complications. METHODS: From 123 patients undergoing single-anesthetic and 154 patients undergoing staged cLF, 95 patients in each group were propensity-matched based on age, sex, BMI, ASA score, smoking, revision, and number of levels. We compared perioperative, 30-day, 90-day, and 1-year complications between the two cohorts. RESULTS: Mean days between stages was 1.58. Single-anesthetic cLF had longer total surgery time (304 vs 240 minutes, p<.001) but shorter total PACU total time (133 vs 196 minutes, p<.001). However, there was no difference in total anesthesia time (368 vs 374 minutes, p=.661) and total EBL (357 vs 320cc, p=.313). Intraoperative complications were nine incidental durotomies in the single-anesthetic and one iliac vein injury in the staged group (9% vs 1%, p=.018). There was no difference of in-hospital (38 vs 31, p=.291), 30-day (16 vs 23, p=.281), 90-day (10 vs 15, p=.391), 1-year complications (9 vs 12, p=.644), and overall cumulative 1-year complications (54 vs 56, p=.883) between the two cohorts. CONCLUSIONS: There is a decrease in total surgical time and intraoperative complications during staged compared with single-anesthetic cLF with no difference in in-hospital, 30-day, 90-day, and 1-year complications between approaches.

Performance of the streamlined quality outcomes database web-based calculator: internal and external validation.

BACKGROUND CONTEXT: With an increasing number of web-based calculators designed to provide the probabilities of an individual achieving improvement after lumbar spine surgery, there is a need to determine the accuracy of these models. PURPOSE: To perform an internal and external validation study of the reduced Quality Outcomes Database web-based Calculator (QOD-Calc). STUDY DESIGN: Observational longitudinal cohort. PATIENT SAMPLE: Patients enrolled study-wide in Quality Outcomes Database (QOD) and patients enrolled in DaneSpine at a single institution who had elective lumbar spine surgery with baseline data to complete QOD-Calc and 12-month postoperative data. OUTCOME MEASURES: Oswestry Disability Index (ODI), Numeric Rating Scales (NRS) for back and leg pain, EuroQOL-5D (EQ-5D). METHODS: Baseline data elements were entered into QOD-Calc to determine the probability for each patient having Any Improvement and 30% Improvement in NRS leg pain, back pain, EQ-5D and ODI. These probabilities were compared with the actual 12-month postop data for each of the QOD and DaneSpine cases. Receiver-operating characteristics analyses were performed and calibration plots created to assess model performance. RESULTS: 24,755 QOD cases and 8,105 DaneSpine lumbar cases were included in the analysis. QOD-Calc had acceptable to outstanding ability (AUC: 0.694-0.874) to predict Any Improvement in the QOD cohort and moderate to acceptable ability (AUC: 0.658-0.747) to predict 30% Improvement. QOD-Calc had acceptable to exceptional ability (AUC: 0.669-0.734) to predict Any improvement and moderate to exceptional ability (AUC: 0.619-0.862) to predict 30% Improvement in the DaneSpine cohort. AUCs for the DaneSpine cohort was consistently lower that the AUCs for the QOD validation cohort. CONCLUSION: QOD-Calc performs well in predicting outcomes in a patient population that is similar to the patients that was used to develop it. Although still acceptable, model performance was slightly worse in a distinct population, despite the fact that the sample was more homogenous. Model performance may also be attributed to the low discrimination threshold, with close to 90% of cases reporting Any Improvement in outcome. Prediction models may need to be developed that are highly specific to the characteristics of the population.

Patient expectations impact patient-reported outcomes and satisfaction after lumbar fusion.

BACKGROUND CONTEXT: Prior studies suggest that patient expectations impact postoperative patient-reported outcomes (PROMs). However, no consensus exists on an appropriate expectations tool. PURPOSE: To examine the impact of patient expectations using a modified version of the Oswestry Disability Index (ODI) on clinical outcomes and patient satisfaction 1 year after lumbar fusion for degenerative pathologies. STUDY DESIGN: Prospective longitudinal cohort. PATIENT SAMPLE: Adults undergoing 1 to 2 level lumbar fusion were identified from four tertiaty spine centers. OUTCOME MEASURES: ODI, EuroQol-5D, Numeric rating scales for back and leg pain. METHODS: Preoperatively, patients completed the ODI, as well as a modified ODI reflecting their expected improvement across the 10 ODI items. For example, item 1 in the ODI asks about Pain Intensity at the moment whereas the Expectations ODI asks "One year after surgery, I expect to have…" The difference between this modified ODI score and the baseline ODI score (Baseine ODI minus Expectations ODI) was defined as the Patient Expectation Score. Patients were stratified into tertiles based on their Expectations score into High (HE), Moderate (ME), and Low (LE) Expectations and compared. RESULTS: There were 30 patients in the HE, 35 in the ME, and 26 in the LE Group, with similar demographics and surgical parameters. Patients in the HE group had worse ODI scores preoperatively (54.96 vs 41.42, p<.001) and were expecting a greater improvement in ODI (43.8 vs 13.5, p<.001). There were fewer patients in the HE group (13, 43%) who reported that they were satisfied with the results compared to either the ME (20, 71%) or LE group (22, 85%, p=.041) despite having similar ODI scores and change in ODI scores 1 year postoperatively. CONCLUSION: An expectations tool, linked to a disease-specific measure may provide the clinician with a practical method of assessing a patient's expectation of results after treatment and aid in the shared decision-making during the preoperative surgical process.

Assessment of the External Validity of Dialogue Support for Predicting Lumbar Spine Surgery Outcomes in a US Cohort.

STUDY DESIGN: External validation using prospectively collected data. OBJECTIVES: To determine the model performance of "Dialogue Support" (DS) in predicting outcomes after lumbar spine surgery. SUMMARY OF BACKGROUND DATA: To help clinicians discuss risk versus benefit with patients considering lumbar fusion surgery, DS has been made available online. As DS was created using a Swedish sample, there is a need to study how well DS performs in alternative populations. PATIENTS AND METHODS: Preoperative data from patients enrolled in the Quality Outcomes Database were entered into DS. The probability for each patient to report satisfaction, achieve success (leg pain improvement ≥3), or have no leg pain 12 months after surgery was extracted and compared with their actual 12-month postoperative data. The ability of DS to identify patients in the Quality Outcomes Database who report satisfaction, achieve success, or have no leg pain 12 months after surgery was determined using Receiver operating characteristic curve analysis, goodness-of-fit tests, and calibration plots. RESULTS: There was a significant improvement in all outcomes in 23,928 cases included in the analysis from baseline to 12 months postoperative. Most (84%) reported satisfaction, 67% achieved success, and 44% were pain-free 12 months postoperative. Receiver operating characteristic analysis showed that DS had a low ability to predict satisfaction [area under the curve (AUC) = 0.606], success (AUC = 0.546), and being pain-free (AUC = 0.578) at 12 months postoperative; poor fit for satisfaction (<0.001) and being pain-free ( P = 0.004), but acceptable fit for success ( P = 0.052). Calibration plots showed underestimation for satisfaction and success, but acceptable estimates for being pain-free. CONCLUSION: DS is not directly transferable to predict satisfaction and success after lumbar surgery in a US population. This may be due to differences in patient characteristics, weights of the variables included, or the exclusion of unknown variables associated with outcomes. Future studies to better understand and improve the transferability of these models are needed.

Opioid-sparing Anesthesia Decreases In-hospital and 1-year Postoperative Opioid Consumption Compared With Traditional Anesthesia: A Propensity-matched Cohort Study.

STUDY DESIGN: Propensity-matched cohort. OBJECTIVE: The aim of this study was to determine if opioid-sparing anesthesia (OSA) reduces in-hospital and 1-year postoperative opioid consumption. SUMMARY OF BACKGROUND DATA: The recent opioid crisis highlights the need to reduce opioid exposure. We developed an OSA protocol for lumbar spinal fusion surgery to mitigate opioid exposure. MATERIALS AND METHODS: Patients undergoing lumbar fusion for degenerative conditions over one to four levels were identified. Patients taking opioids preoperatively were excluded. OSA patients were propensity-matched to non-OSA patients based on age, sex, smoking status, body mass index, American Society of Anesthesiologists grade, and revision versus primary procedure. Standard demographic and surgical data, daily in-hospital opioid consumption, and opioid prescriptions 1 year after surgery were compared. RESULTS: Of 296 OSA patients meeting inclusion criteria, 172 were propensity-matched to non-OSA patients. Demographics were similar between cohorts (OSA: 77 males, mean age=57.69 yr; non-OSA: 67 males, mean age=58.94 yr). OSA patients had lower blood loss (326 mL vs. 399 mL, P =0.014), surgical time (201 vs. 233 min, P <0.001) emergence to extubation time (9.1 vs. 14.2 min, P< 0.001), and recovery room time (119 vs. 140 min, P =0.0.012) compared with non-OSA patients. Fewer OSA patients required nonhome discharge (18 vs. 41, P =0.001) compared with the non-OSA cohort, but no difference in length of stay (90.3 vs. 98.5 h, P =0.204). Daily opioid consumption was lower in the OSA versus the non-OSA cohort from postoperative day 2 (223 vs. 185 morphine milligram equivalents, P =0.017) and maintained each day with lower total consumption (293 vs. 225 morphine milligram equivalents, P =0.003) throughout postoperative day 4. The number of patients with active opioid prescriptions at 1, 3, 6, and 12 months postoperative was statistically fewer in the OSA compared with the non-OSA patients. CONCLUSIONS: OSA for lumbar spinal fusion surgery decreases in-hospital and 1-year postoperative opioid consumption. The minimal use of opioids may also lead to shorter emergence to extubation times, shorter recovery room stays, and fewer discharges to nonhome facilities.

Clinical and Radiographic Outcomes of Repair of Spondylolitic Spondylolisthesis via Direct Pars Repair.

STUDY DESIGN: A retrospective chart review. OBJECTIVE: The objective of this study is to investigate whether direct pars repair achieves bone healing and symptom relief in patients with spondylolitic spondylolisthesis. SUMMARY OF BACKGROUND DATA: While most cases of spondylolysis can be managed non-operatively, a small percentage of patients require surgical intervention. The outcome of direct pars repair via a standard pedicle-screw with wiring technique is controversial in patients with lumbar spondylolitic spondylolisthesis. METHODS: Medical records of patients who had undergone an open surgical pars repair were retrospectively reviewed. Standard demographic and surgical parameters were collected. All patients underwent a primary repair of the pars with autograft or bone morphogenetic protein and instrumentation using a pedicle-screw with spinous process wiring. At 6-12 months after surgery, patient's pain symptoms and postoperative CT scans were independently reviewed to assess healing; graded as non-union, partial union, or solid union. RESULTS: There were 68 patients identified (33 male and 35 female) with an average age of 18.6 years. Mean estimated blood loss was 139 ml, and mean length of hospital stay was 3.7 days. CT evaluation revealed 35 (52%) solid unions, 21 (31%) partial unions, and 12 (18%) non-unions requiring revisions. Thirty-four (50%) patients had no postop pain, 24 (35%) had mild pain, 10 (15%) had persistent pain. The majority of patients with non-unions on CT had mild or persistent pain. Patients with no or mild pain tended to be younger than those with persistent pain (17.5 years vs 24.6 years, P=0.163). CONCLUSION: This study demonstrated a partial or complete union rate of 82% and a postoperative persistent pain rate of 15%. These figures are comparable to the previous study and this pedicle-screw with wiring technique can be worth trying before interbody fusion for spondylolytic spondylolisthesis to preserve anatomical lumbar motion.

The impact of Diabetes in patients with lumbar stenosis - A propensity-score matched study on patient-reported outcomes after surgery.

STUDY DESIGN: Registry-based cohort study. OBJECTIVE: To evaluate the impact of Diabetes (DM) on Patient-reported Outcomes (PROs) after surgery for lumbar spinal stenosis (LSS). METHOD: Patients from the Danish national spine registry, DaneSpine, scheduled for LSS surgery were identified. MRI of patients with and without DM was graded in regards to lumbar stenosis, disc degeneration (DD), muscular fat infiltration, and Modic changes. In addition, preoperative and two-year postoperative data were collected including PROs. Patients with DM were propensity-score matched (PSM) to non-DM patients. RESULTS: In total, 296 patients were included, 41 DM and 255 non-DM. Of these, 27 patients from each group were successfully matched. The PSM DM group had less improvement and worse leg pain at two-year follow-up compared to the non-DM group, VAS 58 vs. 36 (p = 0.004). Physical disability was significantly worse at two-year follow-up in the DM group compared to the non-DM group, Oswestry Disability Index score of 38 vs. 29 (p = 0.05). On the preoperative MRI, the number of patients with severe grade LSS and severe fat infiltration in Multifidus muscles was significantly higher in the PSM DM group compared to the non-DM group, (p < 0.01). CONCLUSION: Patients with concomitant LSS and DM have a significantly reduced improvement in leg pain, more physical disability, and worse leg pain scores at two-year follow-up post-surgery compared to patients without DM. In elderly patients with LSS, there should be an increased focus on DM and the clinically relevant threshold for spine surgery.

Preoperative Optimization: Risk Factors for Perioperative Complications and Preoperative Modification.

Adult spinal deformity (ASD) is common and the complication rate in ASD surgery is high due to its invasiveness. There are several factors that increase the risk of complications with ASD surgery. These include age, past medical history, frailty, osteoporosis, or operative invasiveness. Risk factors for perioperative complications can be categorized as modifiable and non-modifiable. The purpose of this article is to present the current available evidence on risk factors for perioperative complications, with a focus on frailty, osteoporosis, surgical site infection prevention, and hip-spine syndrome. In addition, we present the latest evidence for patient-specific surgical risk assessment and surgical planning.

The Role of Anterior Spine Surgery in Deformity Correction.

There are a range of anterior-based approaches to address flexible adult spinal deformity from the thoracic spine to the sacrum, with each approach offering access to a range of vertebral levels. It includes the transperitoneal (L5-S1), paramedian anterior retroperitoneal (L3-S1), oblique retroperitoneal (L1-2 to L5-S1), the thoracolumbar transdiaphragmatic approach (T9-10 to L4-5), and thoracotomy approach (T4-T12). The lumbar and lumbosacral spine is especially favorable for anterior-based approaches given the relative mobility of the peritoneal organs and position of the vasculature.

Quantitative Romberg on a Force Plate: Objective Assessment Before and After Surgery for Cervical Spondylotic Myelopathy.

STUDY DESIGN: Longitudinal Observational Cohort. OBJECTIVES: The purpose of this study was to evaluate the utility of Quantitative Romberg measurements as pre- and post-op balance outcome measures. SUMMARY OF BACKGROUND DATA: Cervical Spondylotic Myelopathy (CSM) is characterized by balance deficiencies produced by impaired proprioception. Evaluation is subjective and binary physical exam findings lack the precision to assess postoperative outcome improvement. METHODS: CSM patients were prospectively enrolled to undergo pre- and postoperative Quantitative Romberg tests on a force plate to record center of pressure (COP) motion for 30 seconds with eyes open followed by eyes closed. Revision cases were excluded. Kinematics of COP movement parameters were compared between pre- and postoperative state for each patient. RESULTS: Twenty-seven CSM patients were enrolled and completed both pre/post testing. Mean age was 60.0 years with 13 (48%) males, 9 (33%) smokers. Mean number of surgical levels was 2.48. The minimum mean follow-up was six months. There was a statistically significant improvement in eyes closed after surgery compared to pre-operative for total COP motion (523.44 cm vs. 387.00 cm, P<0.001), average sway speed (17.41 cm/s vs. 13.00 cm/s, P<0.001) and total lateral COP motion (253.44 cm vs. 186.70 cm, P<0.001). There was no statistically significant improvement in mJOA (13.29 vs. 14.29, P=0.28). CONCLUSION: CSM balance findings on Quantitative Romberg testing significantly improves postoperatively in patients with CSM. These findings support this testing as representative of proprioceptive balance deficiencies seen in CSM. Quantitative Romberg may be used as an objective measure of clinical outcome and assist in stratification of surgical interventions, surgery timing and technique.

Management of nonpurulent wound drainage following spinal surgery: is empiric oral antibiotic treatment appropriate?

BACKGROUND CONTEXT: Postoperative incisional concerns including nonpurulent drainage are relatively common following spine surgery. Evidence-based management protocols are lacking. PURPOSE: The purpose of this study is to determine if prescribing empiric oral antibiotics for nonpurulent wound drainage is beneficial for the prevention of chronic infection or reoperation. STUDY DESIGN: Retrospective chart review. PATIENT SAMPLE: Patients calling the office with postsurgical wound concerns. OUTCOME MEASURES: Not applicable. METHODS: In a large, multisurgeon, spine surgery practice, a review of the communications log showed that 298 patients called or messaged the office with a concern regarding postoperative nonpurulent wound drainage. Patients were prescribed empiric oral antibiotics based on surgeon preference. Patients who received empiric oral antibiotic treatment (AbxTx) were propensity matched to patients who did not (No AbxTx) based on sex, age, BMI, ASA grade, smoking status, prior spine surgery, anatomic location, and number of surgical levels. The number of patients requiring surgical intervention (debridement) and/or developing a chronic infection was determined. RESULTS: Oral antibiotics were prescribed for 112 of the 298 (38%) patients with reports of nonpurulent drainage. Demographic and surgical characteristics of the two matched cohorts were similar. Although there were more patients in the AbxTx group who required surgical intervention (n=17, 17%) compared to the No AbxTx group (n=9, 9%), this difference was not statistically significant (p=.139). The intra-operative culture results showed no growth in 94% (16/17) of the AbxTx group vs 67% (6/9) of the No AbxTx group (p=.103). One patient in each group required a return to the operating room within the year after the initial surgical debridement for management of chronic infection. CONCLUSION: In this large series (n=298) of patients with nonpurulent wound drainage following spine surgery, 87% resolved without the need for surgical intervention. Empiric oral antibiotics did not reduce the need for surgical intervention or the development of a chronic infection. In addition to the added cost, potential adverse reactions, development of resistant organisms, and inaccurate labeling of surgical site infection; empiric oral antibiotics may lead to a negative intraoperative culture for those requiring surgical intervention impacting the ability to prescribe a specific antibiotic regimen.

Instrumented Versus Uninstrumented Posterolateral Fusion for Lumbar Spondylolisthesis: A Randomized Controlled Trial.

BACKGROUND: In Scandinavia, spinal fusion is frequently performed without instrumentation, as use of instrumentation in the elderly can be complicated by poor bone quality and the risk of screw pull-out. However, uninstrumented fusion carries the risk of nonunion. We performed a randomized controlled trial in an attempt to determine if use of instrumentation leads to better outcomes and fusion rates when spinal fusion is performed for degenerative spondylolisthesis in the elderly. METHODS: This was a randomized, single-center, open-label trial of patients with symptomatic single-level degenerative spondylolisthesis who were assigned 1:1 to decompression and fusion with or without instrumentation after at least 12 weeks of nonoperative treatment had failed. The primary outcome was the change in the Oswestry Disability Index (ODI), and secondary outcomes included fusion rates within 1 year, reoperation rates within 2 years, and changes in the EuroQol-5 Dimension-3 Level (EQ-5D) score. RESULTS: Fifty-four subjects were randomized to each of the 2 groups, which had similar preoperative demographic and surgical characteristics. We found similar improvements in the ODI (p = 0.791), back pain, leg pain, and quality of life between groups at 1 and 2 years of follow-up. Solid fusion on computed tomography (CT) scans was noted in 94% of the patients in the instrumented group and 31% in the uninstrumented group (p < 0.001). One patient (2%) in the instrumented group and 7 (13%) in the uninstrumented group (p = 0.031) had a reoperation within 2 years after the index surgery. CONCLUSIONS: We found no difference in patient-reported outcomes when we compared instrumented with uninstrumented fusion in patients with degenerative spondylolisthesis. The uninstrumented group had a significantly higher rate of nonunion and reoperations at 2 years. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Comparison of revision surgery for pseudarthrosis with or without adjacent segment disease after anterior cervical discectomy and fusion.

Background: Patients with a pseudarthrosis after anterior cervical discectomy and fusion (ACDF) may have concurrent adjacent segment disease (ASD). Although prior studies have shown posterior cervical decompression and fusion (PCDF) is effective in repairing pseudarthrosis, improvement in patient reported outcomes (PROs) has been marginal. The aim of this study is to evaluate the effectiveness of PCDF in achieving symptom relief in patients with pseudarthrosis after ACDF and whether that is altered by the additional treatment of ASD. Methods: Thirty-two patients with pseudarthrosis were compared with 31 patients with pseudarthrosis and concurrent ASD after ACDF who underwent revision PCDF with a minimum 1-year follow-up. Primary outcomes measures included the neck disability index (NDI), and numerical rating scale (NRS) scores for neck and arm pain. Secondary measures included estimated blood loss (EBL), operating room (OR) time, and length of stay. Results: Demographics between cohorts were similar, however there was a significantly higher mean body mass index (BMI) in the group with concurrent ASD (32.23 vs. 27.76, p=.007). Patients with concurrent ASD had more levels fused during PCDF (3.7 vs. 1.9, p<.001), greater EBL (165 cc vs. 106 cc, p=.054), and longer OR time (256 minutes vs. 202 minutes, p<.000). Preoperative PROs for NDI (56.7 vs. 56.5, p=.954), NRS arm pain (5.9 vs. 5.7, p=.758), and NRS neck pain (6.6 vs. 6.8, p=.726) were similar in both cohorts. At 12 months patients with concurrent ASD experienced a slightly greater, but not statistically significant, improvement in PROs (Δ NDI 4.40 vs. -1.44, Δ NRS neck pain 1.17 vs. 0.42, Δ NRS arm pain 1.28 vs. 0.10, p=.107). Conclusions: PCDF is a standard procedure for treatment of pseudarthrosis following ACDF, however improvements in PROs are marginal. Slightly greater improvements were seen in patients whose indication for surgery also included concurrent ASD, rather than a diagnosis of pseudarthrosis alone.

Surgeon input can increase the value of registry data: early experience from the American Spine Registry.

OBJECTIVE: Clear diagnostic delineation is necessary for the development of a strong evidence base in lumbar spinal surgery. Experience with existing national databases suggests that International Classification of Diseases, Tenth Edition (ICD-10) coding is insufficient to support that need. The purpose of this study was to assess agreement between surgeon-specified diagnostic indication and hospital-reported ICD-10 codes for lumbar spine surgery. METHODS: Data collection for the American Spine Registry (ASR) includes an option to denote the surgeon's specific diagnostic indication for each procedure. For cases treated between January 2020 and March 2022, surgeon-delineated diagnosis was compared with the ICD-10 diagnosis generated by standard ASR electronic medical record data extraction. For decompression-only cases, the primary analysis focused on the etiology of neural compression as determined by the surgeon versus that determined on the basis of the related ICD-10 codes extracted from the ASR database. For lumbar fusion cases, the primary analysis compared structural pathology, which may have required fusion, as determined by the surgeon versus that determined on the basis of the extracted ICD-10 codes. This allowed for identification of agreement between surgeon delineation and extracted ICD-10 codes. RESULTS: In 5926 decompression-only cases, agreement between the surgeon and ASR ICD-10 codes was 89% for spinal stenosis and 78% for lumbar disc herniation and/or radiculopathy. Both the surgeon and database indicated no structural pathology (i.e., none) suggesting the need for fusion in 88% of cases. In 5663 lumbar fusion cases, agreement was 76% for spondylolisthesis but poor for other diagnostic indications. CONCLUSIONS: Agreement between surgeon-specified diagnostic indication and hospital-reported ICD-10 codes was best for patients who underwent decompression only. In the fusion cases, agreement with ICD-10 codes was best in the spondylolisthesis group (76%). In cases other than spondylolisthesis, agreement was poor due to multiple diagnoses or lack of an ICD-10 code that reflected the pathology. This study suggested that standard ICD-10 codes may be inadequate to clearly define the indications for decompression or fusion in patients with lumbar degenerative disease.