Timelines for Return to Different Sports Types After Eight Cervical Spine Fractures in Recreational and Elite Athletes: A Survey of the Association for Collaborative Spine Research.

STUDY DESIGN: Prospective cross-sectional survey. OBJECTIVE: To identify timelines for when athletes may be considered safe to return to varying athletic activities after sustaining cervical spine fractures. BACKGROUND: While acute management and detection of cervical spine fractures have been areas of comprehensive investigation, insight into timelines for when athletes may return to different athletic activities after sustaining such fractures is limited. METHODS: A web-based survey was administered to members of the Association for Collaborative Spine Research that consisted of surgeon demographic information and questions asking when athletes (recreational vs elite) with one of 8 cervical fractures would be allowed to return to play noncontact, contact, and collision sports treated nonoperatively or operatively. The third part queried whether the decision to return to sports was influenced by the type of fixation or the presence of radiculopathy. RESULTS: Thirty-three responses were included for analysis. For all 8 cervical spine fractures treated nonoperatively and operatively, significantly longer times to return to sports for athletes playing contact or collision sports compared with recreational and elite athletes playing noncontact sports, respectively (P< 0.05), were felt to be more appropriate. Comparing collision sports with contact sports for recreational and elite athletes, similar times for return to sports for nearly all fractures treated nonoperatively or operatively were noted. In the setting of associated radiculopathy, the most common responses for safe return to play were "when only motor deficits resolve completely" and "when both motor and sensory deficits resolve completely." CONCLUSIONS: In this survey of spine surgeons from the Association for Collaborative Spine Research, reasonable timeframes for return to play for athletes with 8 different cervical spine fractures treated nonoperatively or operatively varied based on fracture subtype and level of sporting physicality.

Coronal Alignment in Adult Spine Surgery.

Coronal realignment is an important goal in adult spine surgery that has been overshadowed by emphasis on the sagittal plane. As coronal malalignment drives considerable functional disability, a fundamental understanding of its clinical and radiographic evaluation and surgical techniques to prevent its development is of utmost importance. In this study, we review etiologies of coronal malalignment and their radiographic and clinical assessments, risk factors for and functional implications of postoperative coronal malalignment, and surgical strategies to optimize appropriate coronal realignment in adult spine surgery.

Abdominal lymphocele following multi-level anterior lumbar interbody fusion (ALIF) managed with a laparoscopic peritoneal window: case report and review of the literature.

PURPOSE: Lymphocele formation following anterior lumbar interbody fusion (ALIF) is not common, but it can pose diagnostic and treatment challenges. The purpose of this case is to report for the first time the treatment of a postoperative lymphocele following a multi-level ALIF using a peritoneal window made through a minimally invasive laparoscopic approach. METHODS: Case report. RESULTS: A 74-year-old male with a history of prostatectomy and pelvic radiation underwent a staged L3-S1 ALIF (left paramedian approach) and T10-pelvis posterior instrumented with L1-5 decompression/posterior column osteotomies for degenerative scoliosis and neurogenic claudication. Three weeks after surgery, swelling of the left abdomen and entire left leg was reported. Computed tomography of the abdomen/pelvis demonstrated a large (19.2 × 12.0 × 15.4 cm) retroperitoneal fluid collection with compression of the left ureter and left common iliac vein. Fluid analysis (80% lymphocytes) was consistent with a lymphocele. Percutaneous drainage for 4 days was ineffective at clearing the lymphocele. For more definitive management, the patient underwent an uncomplicated laparoscopic creation of a peritoneal window to allow passive drainage of lymphatic fluid into the abdomen. Three years after surgery, he had no back or leg pain, had achieved spinal union, and had no abdominal swelling or left leg swelling. Advanced imaging also confirmed resolution of the lymphocele. CONCLUSIONS: In this case report, creation of a peritoneal window minimally invasively via a laparoscope allowing passive drainage of lymphatic fluid into the abdomen was safe and effective for management of an abdominal lymphocele following a multi-level ALIF.

Proximal Junctional Kyphosis and Failure: Strategies for Prevention.

Proximal junctional kyphosis (PJK) and proximal junctional failure/fractures (PJF) are common complications following long-segment posterior instrumented fusions for adult spinal deformity. As progression to PJF involves clinical consequences for patients and requires costly revisions that may undermine the utility of surgery and are ultimately unsustainable for health care systems, preventative strategies to minimize the occurrence of PJF are of tremendous importance. In this article, the authors present a detailed outline of PJK and PJF with a focus on surgical strategies aimed at preventing their occurrence..

Aortic arch and frozen elephant trunk repair of a right-sided aortic arch with pseudoaneurysm rupture.

A 53-year-old man with a history of vascular ring repair secondary to a right-sided aortic arch with a retroesophageal subclavian artery and ligamentum arteriosum to the descending thoracic aorta presented to our institution with a large aortic pseudoaneurysm of the distal aortic arch. Computed tomography demonstrated a right-sided aortic arch with a 5.8-cm pseudoaneurysm arising from the distal arch with concern for rupture. The patient underwent successful two-stage repair, including a left carotid artery to subclavian artery bypass, followed by total arch replacement with the frozen elephant trunk technique. He recovered well postoperatively, and computed tomography showed complete, successful repair of the pseudoaneurysm.

Lumbar Pedicle Subtraction Osteotomy (PSO): A Novel Surgical Technique for Correction of Sagittal and Coronal Imbalance Using Laterally Based Satellite Rods.

STUDY DESIGN: Operative video and supplemental manuscript. OBJECTIVE: To present a novel step-by-step approach to performing a lumbar pedicle subtraction osteotomy (PSO) using laterally based satellite rods. SUMMARY OF BACKGROUND DATA: Multi-rod constructs have demonstrated paramount for decreasing rates of pseudarthrosis after PSOs. Multi-rods constructs can be achieved using either "satellite" rods (rods not connected to the primary rods) and/or "accessory rods" (rods connected to the primary rods). METHODS: A step-by-step approach to performing a lumbar PSO using a laterally based satellite rod configuration is provided through a case example and surgical technique video. RESULTS: Lateral satellite rods can be particularly useful from a surgical perspective, as they provide temporary stabilization while the PSO is being performed, facilitate closure of the osteotomy site (symmetric and/or asymmetric), and serve as the final fixation rods across the PSO without needing to be exchanged. CONCLUSIONS: Use of laterally based satellite rods is a useful technique for lumbar PSOs, as they provide temporary stabilization while the PSO is being performed, facilitate closure of the osteotomy site, and serve as the final fixation rods across the PSO without needing to be exchanged.

Navigated Hybrid Open/Muscle-sparing Approach to 2-level Cement Augmentation of the UIV and UIV+1 for Prevention of Proximal Junctional Failure: Supplemental Manuscript to Operative Video.

STUDY DESIGN: Operative video and supplemental manuscript. OBJECTIVE: To present a cement augmentation technique of the upper instrumented vertebra (UIV) and UIV+1 for prevention of proximal junctional fractures (PJFs) in multi-level thoracolumbar posterior instrumented fusions. SUMMARY OF BACKGROUND DATA: PJFs are unfortunately a common occurrence after multi-level thoracolumbar instrumented fusions to the pelvis for adult spinal deformity that can result in significant functional disability and often require costly revision operations. As such, their prevention is key. METHODS: A surgical video illustrates the nuances of a 2-level cement augmentation technique, consisting of an open vertebroplasty of the UIV through fenestrated screws and a muscle-sparing kyphoplasty of the UIV+1. RESULTS: Utility of performing an open vertebroplasty of the UIV through fenestrated screws and muscle-sparing kyphoplasty of the UIV+1 lies in its ability to minimize soft-tissue disruption at the adjacent segment while providing additional structural support to the anterior column at this high-risk zone. CONCLUSIONS: Cement augmentation of the UIV and UIV+1 consisting of a hybrid open vertebroplasty and muscle-sparing kyphoplasty can be an effective strategy to decrease the incidence of PJF after multi-level posterior thoracolumbar instrumented fusions to the pelvis for adult spinal deformity.

Duration of neurological deficit and outcomes in the surgical treatment of spinal coccidioidomycosis.

OBJECTIVE: Vertebral osteomyelitis is a rare complication of coccidioidomycosis infection. Surgical intervention is indicated when there is failure of medical management or presence of neurological deficit, epidural abscess, or spinal instability. The relationship between timing of surgical intervention and recovery of neurological function has not been previously described. The purpose of this study was to investigate if the duration of neurological deficits at presentation affects neurological recovery after surgical intervention. METHODS: This was a retrospective study of all patients diagnosed with coccidioidomycosis involving the spine at a single tertiary care center between 2012 and 2021. Data collected included patient demographics, clinical presentation, radiographic information, and surgical intervention. The primary outcome was change in neurological examination after surgical intervention, quantified according to the American Spinal Injury Association Impairment Scale. The secondary outcome was the complication rate. Logistic regression was used to test if the duration of neurological deficits was associated with improvement in the neurological examination after surgery. RESULTS: Twenty-seven patients presented with spinal coccidioidomycosis between 2012 and 2021; 20 of these patients had vertebral involvement on spinal imaging with a median follow-up of 8.7 months (IQR 1.7-71.2 months). Of the 20 patients with vertebral involvement, 12 (60.0%) presented with a neurological deficit with a median duration of 20 days (range 1-61 days). Most patients presenting with neurological deficit (11/12, 91.7%) underwent surgical intervention. Nine (81.2%) of these 11 patients had an improved neurological examination after surgery and the other 2 had stable deficits. Seven patients had improved recovery sufficient to improve by 1 grade according to the AIS. The duration of neurological deficits on presentation was not significantly associated with neurological improvement after surgery (p = 0.49, Fisher's exact test). CONCLUSIONS: The duration of neurological deficits on presentation should not deter surgeons from operative intervention in cases of spinal coccidioidomycosis.

Patient Frailty Influences Outcome After Open, But Not Minimally Invasive, Transforaminal Interbody Fusion: A Case Series of 115 Patients With Lumbar Degenerative Disease.

BACKGROUND: For transforaminal lumbar interbody fusion (TLIF), there are equally good open and minimally invasive surgery (MIS) options. OBJECTIVE: To determine if frailty has a differential effect on outcome for open vs MIS TLIF. METHODS: We performed a retrospective review of 115 TLIF surgeries (1-3 levels) for lumbar degenerative disease performed at a single center; 44 MIS transforaminal interbody fusions and 71 open TLIFs were included. All patients had at least a 2-year follow up, and any revision surgery during that time was recorded. The Adult Spinal Deformity Frailty Index (ASD-FI) was used to separate patients into nonfrail (ASD-FI < 0.3) and frail (ASD-FI > 0.3) cohorts. The primary outcome variables were revision surgery and discharge disposition. Univariate analyses were performed to reveal associations in demographic, radiographic, and surgical data with the outcome variables. Multivariate logistic regression was used to assess independent predictors of outcome. RESULTS: Frailty uniquely predicted both reoperation (odds ratio 8.1, 95% CI 2.5-26.1, P = .0005) and discharge to a location other than home (odds ratio 3.9, 95% CI 1.2-12.7, P = .0239). Post hoc analysis indicated that frail patients undergoing open TLIF had a higher revision surgery rate (51.72%) compared with frail patients undergoing MIS-TLIF (16.7%). Nonfrail patients undergoing open and MIS TLIF had a revision surgery rate of 7.5% and 7.7%, respectively. CONCLUSION: Frailty was associated with increased revision rate and increased probability to discharge to a location other than home after open transforaminal interbody fusions, but not MIS transforaminal interbody fusions. These data suggest that patients with high frailty scores may benefit from MIS-TLIF procedures.

Predictive models to assess risk of extended length of stay in adults with spinal deformity and lumbar degenerative pathology: development and internal validation.

BACKGROUND CONTEXT: Postoperative recovery after adult spinal deformity (ASD) operations is arduous, fraught with complications, and often requires extended hospital stays. A need exists for a method to rapidly predict patients at risk for extended length of stay (eLOS) in the preoperative setting. PURPOSE: To develop a machine learning model to preoperatively estimate the likelihood of eLOS following elective multi-level lumbar/thoracolumbar spinal instrumented fusions (≥3 segments) for ASD. STUDY DESIGN/SETTING: Retrospectively from a state-level inpatient database hosted by the Health care cost and Utilization Project. PATIENT SAMPLE: Of 8,866 patients of age ≥50 with ASD undergoing elective lumbar or thoracolumbar multilevel instrumented fusions. OUTCOME MEASURES: The primary outcome was eLOS (>7 days). METHODS: Predictive variables consisted of demographics, comorbidities, and operative information. Significant variables from univariate and multivariate analyses were used to develop a logistic regression-based predictive model that use six predictors. Model accuracy was assessed through area under the curve (AUC), sensitivity, and specificity. RESULTS: Of 8,866 patients met inclusion criteria. A saturated logistic model with all significant variables from multivariate analysis was developed (AUC=0.77), followed by generation of a simplified logistic model through stepwise logistic regression (AUC=0.76). Peak AUC was reached with inclusion of six selected predictors (combined anterior and posterior approach, surgery to both lumbar and thoracic regions, ≥8 level fusion, malnutrition, congestive heart failure, and academic institution). A cutoff of 0.18 for eLOS yielded a sensitivity of 77% and specificity of 68%. CONCLUSIONS: This predictive model can facilitate identification of adults at risk for eLOS following elective multilevel lumbar/thoracolumbar spinal instrumented fusions for ASD. With a fair diagnostic accuracy, the predictive calculator will ideally enable clinicians to improve preoperative planning, guide patient expectations, enable optimization of modifiable risk factors, facilitate appropriate discharge planning, stratify financial risk, and accurately identify patients who may represent high-cost outliers. Future prospective studies that validate this risk assessment tool on external datasets would be valuable.

Posterior-based resection of spinal meningiomas: an institutional experience of 141 patients with an average of 28 months of follow-up.

OBJECTIVE: Spinal meningiomas pose unique challenges based on the location of their dural attachment. However, there is a paucity of literature investigating the role of dural attachment location on outcomes after posterior-based approach for spinal meningioma resection. The aim of this study was to investigate any differences in outcomes between dural attachment location subgroups in spinal meningioma patients who underwent posterior-based resection. METHODS: This was a single-institution review of patients who underwent resection of a spinal meningioma from 1997 to 2017. Surgical, oncological, and neurological outcomes were compared between patients with varying dural attachments. Multivariate analysis was utilized. RESULTS: A total of 141 patients were identified. The mean age was 62 years, and 110 women were included. The sites of dural attachments were as follows: 16 (11.3%) dorsal, 31 (22.0%) dorsolateral, 17 (12.1%) lateral, 40 (28.4%) ventral, and 37 (26.2%) ventrolateral. Most meningiomas were WHO grade I (92.2%) and in the thoracic spine (61.0%). All patients underwent a posterior approach for tumor resection. There were no differences between subgroups in terms of largest diameter of tumor resected (p = 0.201), gross-total resection (GTR) or subtotal resection (p = 0.362), Simpson grade of resection, perioperative complications (p = 0.116), long-term neurological deficit (p = 0.100), or postoperative radiation therapy (p = 0.971). Cervical spine location was associated with reduced incidence of GTR (OR 0.271, 95% CI 0.108-0.684, p = 0.006) on multivariate analysis. The overall incidence of recurrence/progression was 4.6%, with no difference (p = 0.800) between subgroups. Similarly, the average length of follow-up was 28.1 months, with no difference between subgroups (p = 0.413). CONCLUSIONS: Posterior-based approaches for resection of spinal meningiomas are safe and effective, regardless of dural attachment location, with similar surgical, oncological, and neurological outcomes. Comparison of long-term recurrence rates between dural attachment subgroups is required.

Development and internal validation of predictive models to assess risk of post-acute care facility discharge in adults undergoing multi-level instrumented fusions for lumbar degenerative pathology and spinal deformity.

PURPOSE: To develop a model for factors predictive of Post-Acute Care Facility (PACF) discharge in adult patients undergoing elective multi-level (≥ 3 segments) lumbar/thoracolumbar spinal instrumented fusions. METHODS: The State Inpatient Databases acquired from the Healthcare Cost and Utilization Project from 2005 to 2013 were queried for adult patients who underwent elective multi-level thoracolumbar fusions for spinal deformity. Outcome variables were classified as discharge to home or PACF. Predictive variables included demographic, pre-operative, and operative factors. Univariate and multivariate logistic regression analyses informed development of a logistic regression-based predictive model using seven selected variables. Performance metrics included area under the curve (AUC), sensitivity, and specificity. RESULTS: Included for analysis were 8866 patients. The logistic model including significant variables from multivariate analysis yielded an AUC of 0.75. Stepwise logistic regression was used to simplify the model and assess number of variables needed to reach peak AUC, which included seven selected predictors (insurance, interspaces fused, gender, age, surgical region, CCI, and revision surgery) and had an AUC of 0.74. Model cut-off for predictive PACF discharge was 0.41, yielding a sensitivity of 75% and specificity of 59%. CONCLUSIONS: The seven variables associated significantly with PACF discharge (age > 60, female gender, non-private insurance, primary operations, instrumented fusion involving 8+ interspaces, thoracolumbar region, and higher CCI scores) may aid in identification of adults at risk for discharge to a PACF following elective multi-level lumbar/thoracolumbar spinal fusions for spinal deformity. This may in turn inform discharge planning and expectation management.

Failure in Adult Spinal Deformity Surgery: A Comprehensive Review of Current Rates, Mechanisms, and Prevention Strategies.

STUDY DESIGN: Literature review. OBJECTIVE: The aim of this review is to summarize recent literature on adult spinal deformity (ASD) treatment failure as well as prevention strategies for these failure modes. SUMMARY OF BACKGROUND DATA: There is substantial evidence that ASD surgery can provide significant clinical benefits to patients. The volume of ASD surgery is increasing, and significantly more complex procedures are being performed, especially in the aging population with multiple comorbidities. Although there is potential for significant improvements in pain and disability with ASD surgery, these procedures continue to be associated with major complications and even outright failure. METHODS: A systematic search of the PubMed database was performed for articles relevant to failure after ASD surgery. Institutional review board approval was not needed. RESULTS: Failure and the potential need for revision surgery generally fall into 1 of 4 well-defined phenotypes: clinical failure, radiographic failure, the need for reoperation, and lack of cost-effectiveness. Revision surgery rates remain relatively high, challenging the overall cost-effectiveness of these procedures. CONCLUSION: By consolidating the key evidence regarding failure, further research and innovation may be stimulated with the goal of significantly improving the safety and cost-effectiveness of ASD surgery.

Proximal Junctional Spondylodiscitis Following Adult Spinal Deformity Surgery: Case Series and Review of the Literature.

BACKGROUND: Proximal junctional failure (PJF) following multilevel thoracolumbar instrumented to the pelvis for adult spinal deformity (ASD) is relatively uncommon but considerably disabling. While the leading etiology is mechanical, other rarer etiologies can play a role in its development. The purpose of this study was to present a case series of ASD patients who experienced PJF secondary to proximal junctional spondylodiscitis (PJS) after long-segment thoracolumbar posterior instrumented fusions. METHODS: Adult patients who underwent posterior instrumented fusions at a single academic center between 2017 and 2020 and subsequently developed PJS were retrospectively reviewed. Patient demographics, operative details, clinical presentation, culture data, and management approach were evaluated. RESULTS: Three patients developed PJS and were included for analysis (mean age 67 years [range, 58-76]; women: 2). Indication for all index operations was symptomatic ASD after failed conservative management. Clinical presentation ranged from mild back pain to severe neurological compromise. Average time to infection and PJF after the index procedure was 11 months (range, 3 months-2 years). All 3 patients were successfully managed with urgent revision surgery including surgical debridement and postoperative antibiotics. CONCLUSION: PJS is a rare yet potentially devastating complication following long-segment posterior thoracolumbar instrumented fusions for ASD. It is critical that surgeons maintain a high index of suspicion of infection when managing PJF given the potential neurological morbidity of PJS. CLINICAL RELEVANCE: This report highlights a rare but important cause of PJF following ASD surgery. It is critical that one maintains a high index of suspicion of infection when managing PJF.

Lidocaine Infusion for the Management of Postoperative Pain and Delirium (LIMPP): protocol for a randomised control trial.

INTRODUCTION: Postoperative delirium is a frequent adverse event following elective non-cardiac surgery. The occurrence of delirium increases the risk of functional impairment, placement to facilities other than home after discharge, cognitive impairment at discharge, as well as in-hospital and possibly long-term mortality. Unfortunately, there is a dearth of effective strategies to minimise the risk from modifiable risk factors, including postoperative pain control and the analgesic regimen. Use of potent opioids, currently the backbone of postoperative pain control, alters cognition and has been associated with an increased risk of postoperative delirium. Literature supports the intraoperative use of lidocaine infusions to decrease postoperative opioid requirements, however, whether the use of postoperative lidocaine infusions is associated with lower opioid requirements and subsequently a reduction in postoperative delirium has not been investigated. METHODS AND ANALYSIS: The Lidocaine Infusion for the Management of Postoperative Pain and Delirium trial is a randomised, double-blinded study of a postoperative 48-hour infusion of lidocaine at 1.33 mg/kg/hour versus placebo in older patients undergoing major reconstructive spinal surgery at the University of California, San Francisco. Our primary outcome is incident delirium measured daily by the Confusion Assessment Method in the first three postoperative days. Secondary outcomes include delirium severity, changes in cognition, pain scores, opioid use, incidence of opioid related side effects and functional benefits including time to discharge and improved recovery from surgery. Lidocaine safety will be assessed with daily screening questionnaires and lidocaine plasma levels. ETHICS AND DISSEMINATION: This study protocol has been approved by the ethics board at the University of California, San Francisco. The results of this study will be published in a peer-review journal and presented at national conferences as poster or oral presentations. Participants wishing to know the results of this study will be contacted directly on data publication. TRIAL REGISTRATION NUMBER: NCT05010148.

Economic Impact of Revision Operations for Adjacent Segment Disease of the Subaxial Cervical Spine.

INTRODUCTION: Adjacent segment disease (ASD) of the cervical spine is a common disabling phenomenon that often requires surgical intervention. The goal of this study was to evaluate the economic impact of revision operations for cervical ASD. METHODS: Consecutive adults who underwent revision cervical spine surgery for ASD at a single institution between 2014 and 2017 were retrospectively reviewed. Direct costs were identified from medical billing data and calculated for each revision surgery for ASD. Incomplete cost data for revision operations were used as a criterion for exclusion. Cost data were stratified based on the approach of the index and revision operations. RESULTS: Eighty-five patients (average age 57 ± 10 years) underwent revisions for cervical ASD, which summed to $2 million (average $23,702). Revisions consisted of 45 anterior operations (anterior cervical diskectomy and fusion, 34; corpectomy, 10; and cervical disk arthroplasty, 1), 32 posterior operations (posterior cervical fusion, 14; foraminotomy, 14; and laminoplasty, 4), and 8 circumferential operations. Circumferential revisions had notably higher average direct costs ($57,376) than single approaches (anterior, $20,084 and posterior, $20,371). Of posterior revisions, foraminotomies had the lowest average direct costs ($5,389), whereas posterior cervical fusion had the highest average direct costs ($35,950). Of anterior revisions, corpectomies ($30,265) had notably greater average direct costs than anterior cervical diskectomy and fusion ($17,514). Costs were not notably different for revision approaches based on the index operations' approach. DISCUSSION: Revision operations for cervical ASD are highly heterogeneous and associated with an average direct cost of $27,702. Over 3 years, revisions for 85 patients with cervical ASD represented a notable economic expense (greater than $2.0 million). DATA AVAILABILITY: Deidentified data may be provided by request to the corresponding author.

RAPT score and preoperative factors to predict discharge location following adult spinal deformity surgery.

PURPOSE: To assess factors, including RAPT score, predictive of non-home discharges following adult spinal deformity (ASD) operations. METHODS: Adults who underwent thoracolumbar instrumented fusions to the pelvis for ASD (1/2019-1/2020) were reviewed. Patient demographics, RAPT metrics, hospital length of stay (LOS), operative details, and complications were compared between patients discharged home and non-home. Univariate and multivariate analyses were performed using logistic regression to determine the relative risk of non-home discharge. Area Under the Receiver Operating Characteristic curve (AUROC) for RAPT score and non-home discharge was also determined. RESULTS: Ninety-nine patients (average age 68 ± 9 years; female-64; average RAPT 8.6 ± 2.2) were analyzed. Operations had the following characteristics: average # levels fused 11 ± 3, revisions 54%, anterior-posterior 70%, 3-column osteotomies 23%. Average LOS was 8.5 ± 3.6 days. The majority of patients (75.8%) had non-home discharges. Non-home discharges had significantly lower RAPT scores (8.3 vs. 9.6; p = 0.02), more advanced age (70 vs. 63 years; p = 0.01), and higher Charlson Comorbidity Index (CCI) scores (3.6 vs. 2.5; p < 0.01) compared to home discharges. On univariate analysis, factors significantly associated with non-home discharge were older age [relative risk (RR) 1.09, p < 0.01], higher CCI (RR 1.73, p = 0.01), total # levels fused (RR 1.24, p = 0.04), and lower RAPT scores (RR 0.71, p = 0.01). RAPT score < 8 was most predictive of non-home discharge (RR 4.87, p = 0.04). An AUROC relating RAPT scores and non-home discharge was 0.7. CONCLUSIONS: Non-home discharges after ASD operations are common. Of the four factors associated with non-home discharges (elderly age, higher CCI, total number of levels fused, RAPT score), a RAPT score < 8 was most predictive. The RAPT score holds promising utility for pre-operative patient counseling and discharge planning for adults undergoing operations for spinal deformity.

Anterior Lumbar Interbody Fusion With Cage Retrieval for the Treatment of Pseudarthrosis After Transforaminal Lumbar Interbody Fusion: A Single-Institution Case Series.

BACKGROUND: The treatment of pseudarthrosis after transforaminal lumbar interbody fusion (TLIF) can be challenging, particularly when anterior column reconstruction is required. There are limited data on TLIF cage removal through an anterior approach. OBJECTIVE: To assess the safety and efficacy of anterior lumbar interbody fusion (ALIF) as a treatment for pseudarthrosis after TLIF. METHODS: ALIFs performed at a single academic medical center were reviewed to identify cases performed for the treatment of pseudarthrosis after TLIF. Patient demographics, surgical characteristics, perioperative complications, and 1-yr radiographic data were collected. RESULTS: A total of 84 patients were identified with mean age of 59 yr and 37 women (44.0%). A total of 16 patients (19.0%) underwent removal of 2 interbody cages for a total of 99 implants removed with distribution as follows: 1 L2/3 (0.9%), 6 L3/4 (5.7%), 37 L4/5 (41.5%), and 55 L5/S1 (51.9%). There were 2 intraoperative venous injuries (2.4%) and postoperative complications were as follows: 7 ileus (8.3%), 5 wound-related (6.0%), 1 rectus hematoma (1.1%), and 12 medical complications (14.3%), including 6 pulmonary (7.1%), 3 cardiac (3.6%), and 6 urinary tract infections (7.1%). Among 58 patients with at least 1-yr follow-up, 56 (96.6%) had solid fusion. There were 5 cases of subsidence (6.0%), none of which required surgical revision. Two patients (2.4%) required additional surgery at the level of ALIF for pseudarthrosis. CONCLUSION: ALIF is a safe and effective technique for the treatment of TLIF cage pseudarthrosis with a favorable risk profile.