Effect of Preoperative Motor Weakness on Postoperative Clinical Outcomes in Patients Undergoing Cervical Disk Replacement.

STUDY DESIGN: This is a retrospective review. OBJECTIVE: To examine the effect of preoperative motor weakness on clinical outcomes in patients undergoing cervical disk replacement (CDR). SUMMARY OF BACKGROUND DATA: Studies examining the effect of preoperative motor weakness on postoperative clinical outcomes in CDR are limited. METHODS: Patient cohorts were based on documented upper-extremity motor weakness on physical exam versus no motor weakness. Demographics, perioperative characteristics, and preoperative patient-reported outcome measures (PROMs) were compared using univariate inferential statistics. PROMs consisted of Visual Analog Pain Scale-Neck (VAS-N), Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), VAS-Arm (VAS-A), 12-Item Short Form (SF-12) Physical Component Score (PCS), Oswestry Neck Disability Index (NDI), and SF-12 Mental Component Score (MCS). Postoperative PROMs were collected at the 6-week, 12-week, 6-month, and final follow-up up to 1-yeartime points, and intercohort minimum clinically important difference (MCID) achievement was compared through multivariable linear logistic regression adjusting for significant differences in preoperative characteristics. RESULTS: A total of 118 patients formed cohorts based on documented upper-extremity weakness (n=73) versus no weakness (n=45). The average time to postoperative follow-up was 9.7±7.0 mo. The differences in insurance type between the 2 cohorts were significant (P<0.042). Perioperative diagnosis of foraminal stenosis was significantly more common in the motor weakness cohort (P<0.013). There were no differences in reported PROMs between cohorts. Patients with motor weakness reported significant MCID achievement for PROMIS-PF at 6-/12-weeks (P<0.012, P<0.041 respectively), SF-12 PCS at 6-months (P<0.042), VAS-N at final follow-up (P<0.021), and NDI at final follow-up (P<0.013). CONCLUSIONS: CDR patients with preoperative muscle weakness achieved MCID across several PROMs compared with patients without muscle weakness. Patients with motor weakness reported greater improvement in mental health, pain, and disability as early as 6 weeks and up to 1 year after CDR. This information serves to inform physicians that motor weakness may not indicate a negative overall outcome.

Worse Preoperative 12-Item Veterans Rand Physical Component Scores Prognosticate Inferior Outcomes Following Outpatient Lumbar Decompression.

STUDY DESIGN: Retrospective Review. OBJECTIVE: Evaluate the influence of the 12-Item veterans Rand (VR-12) physical component score (PCS) on patient-reported outcome measures (PROMs) in an outpatient lumbar decompression (LD) cohort. SUMMARY OF BACKGROUND DATA: The influence of baseline VR-12 PCS on postoperative clinical outcomes has not been evaluated in patients undergoing outpatient LD. METHODS: Patients undergoing primary, elective, 1/2-level outpatient LD with baseline VR-12 PCS scores were retrospectively identified from a prospectively maintained single-surgeon database. Cohorts were preoperative VR-12 PCS<30 and VR-12 PCS≥30. Patient/perioperative characteristics and preoperative/postoperative 6-week/final follow-up (FF) PROMs were collected. Physical health PROMs included the VR-12 PCS, 12-Item Short Form (SF-12) PCS, patient-reported outcome measure information system-physical function (PROMIS-PF), visual analog scale (VAS)-back/leg, and Oswestry disability index (ODI). Mental health PROMs included the VR-12/SF-12 mental component score (MCS) and the patient-health questionnaire-9 (PHQ-9). Average FF was 13.8±8.9 months postoperatively. PROM improvements at 6 weeks/FF and minimal clinically important difference (MCID) achievement rates were determined. χ2 analysis and the Student's t tests compared demographics, perioperative data, and preoperative PROMs. Multivariate linear/logistic regression compared postoperative PROMs, PROM improvements, and MCID achievement rates. RESULTS: Six weeks postoperatively, VR-12 PCS<30 reported worse baseline PROMs (P≤0.042, all) and worse scores except VR-12/SF-12 MCS (P≤0.043, all). Compared with VR-12 PCS≥30, VR-12 PCS<30 had worse FF VR-12 PCS, SF-12 PCS/MCS, PROMIS-PF, PHQ-9, and VAS-Back (P≤0.033, all). VR-12 PCS<30 experienced greater 6-week improvements in VR-12/SF-12 PCS, PHQ-9, VAS-Back, and ODI (P≤0.039, all). VR-12 PCS<30 had greater FF improvements in VR-12/SF-12 PCS, PHQ-9, and ODI (P≤0.001, all) and greater overall MCID achievement in VR-12 PCS/MCS, SF-12 PCS, PHQ-9, and ODI (P≤0.033, all). CONCLUSIONS: VR-12 PCS<30 patients-reported worse baseline/postoperative mental/physical health scores. However, they reported greater improvements in physical function, depressive burden, back pain, and disability by 6 weeks and FF and experienced greater MCID achievement for physical functioning, mental health, and disability scores.

Worse Pain and Disability at Presentation Predicts Greater Improvement in Pain, Disability, and Mental Health in Patients Undergoing Minimally Invasive Transforaminal Lumbar Interbody Fusion for Degenerative Spondylolisthesis.

STUDY DESIGN: Retrospective Review. OBJECTIVE: To assess the impact of preoperative pain and disability on patient-reported outcome measures (PROMs) following minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for degenerative spondylolisthesis. SUMMARY OF BACKGROUND DATA: Varying preoperative symptom severity in lumbar fusion patients alters perceptions of surgical success. METHODS: Degenerative spondylolisthesis patients undergoing elective, primary, single-level MI-TLIF were stratified by preoperative symptom severity: Mild (VAS-B<7/ODI<50), Moderate (VAS-B≥7/ODI<50 or VAS-B<7/ODI≥50), and Severe (VAS-B≥7/ODI≥50). PROMs, Patient-reported Outcomes Measurement Information System-Physical Function (PROMIS-PF), ODI, VAS-B, VAS-Leg (VAS-L), and 9-item Patient Health Questionnaire (PHQ-9) were compared at baseline, 6 weeks, and final follow-up (µ=16.3±8.8 mo). Postoperative PROMs, magnitudes of improvement, and minimal clinically important difference (MCID) achievement rates were compared between cohorts through multivariable regression. RESULTS: A total of 177 patients were included. Acute postoperative pain and narcotic consumption were highest in the severe cohort (P≤0.003). All preoperative PROMs worsened from mild to severe cohorts (P<0.001). All PROMs continued to be significantly different between cohorts at 6 weeks and final follow-up, with the worst scores in the Severe cohort (P≤0.003). At 6 weeks, all cohorts improved in ODI, VAS-B, VAS-L, and PHQ-9 (P≤0.003), with the Moderate cohort also improving in PROMIS-PF (P=0.017). All Cohorts improved across PROMs at the final follow-up (P≤0.044). Magnitudes of improvement in ODI, VAS-B, and PHQ-9 increased with worsening preoperative symptom severity (P≤0.042). The Moderate and Severe cohorts demonstrated higher MCID achievement in ODI, VAS-B, and PHQ-9 rates than the Mild cohort. CONCLUSIONS: Despite preoperative pain and disability severity, patients undergoing MI-TLIF for degenerative spondylolisthesis report significant improvement in physical function, pain, disability, and mental health postoperatively. Patients with increasing symptom severity continued to report worse severity postoperatively compared with those with milder symptoms preoperatively but were more likely to report larger improvements and achieve clinically meaningful improvement in disability, pain, and mental health.

Impact of Early Depressive Burden on Patient-Reported Outcomes Following Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective review. OBJECTIVE: To evaluate mental health influence on minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) patients. SUMMARY OF BACKGROUND DATA: Poor mental health has been postulated to indicate inferior patient perceptions of surgical outcomes in spine literature. Few studies have assessed mental health as a dynamic metric throughout the perioperative period. METHODS: A single-surgeon database was retrospectively searched for patients who underwent primary, elective MIS-TLIF for degenerative or isthmic spondylolisthesis. Summative depressive burden (SDB) was defined by the sum of preoperative and 6-week postoperative 9-item Patient Health Questionnaire (PHQ-9), with Lesser Burden (LB, SDB<10) and Greater Burden (GB, SDB≥10) cohorts. Patient-reported outcomes measures (PROMs) were compared preoperatively, at 6 weeks, and at final postoperative follow-up (11.4±10.9 mo), using Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF), Oswestry disability index (ODI), visual analog scale-back (VAS-B), VAS-leg (VAS-L), and PHQ-9. Improvements at 6-week (∆PROM-6W), final follow-up (∆PROM-FF), and minimum clinically important difference (MCID) achievement were compared. RESULTS: The GB cohort consisted of 44 of 105 patients. Demographic variations included older age, higher Charlson comorbidity index, increased hypertension prevalence, and private insurance in the LB cohort (P≤0.018). The LB cohort demonstrated better baseline and 6-week PROMIS-PF/ODI/VAS-L (P≤0.032) and better final PROMIS-PF/ODI/VAS-L/PHQ-9 (P≤0.031). Both cohorts improved in all PROMs at 6 weeks and final follow-up (P≤0.029), except for PROMIS-PF at 6 weeks in the GB cohort. ∆PROM-6W, ∆PROM-FF, and MCID achievement rate for PHQ-9 were greater in the GB cohort (P≤0.001). CONCLUSION: On average, patients undergoing MIS-TLIF for degenerative or isthmic spondylolisthesis improved in all PROMs by final follow-up. Patients with GB suffered inferior perceptions of physical function, disability, and leg pain. MCID rates in mental health were higher for GB cohort. Surgeons are encouraged to adopt a compassionate understanding of depressive burden and educate the patient on possible consequential postoperative outcomes.

Prognostic value in preoperative Veterans RAND-12 mental Component score on clinical outcomes for patients undergoing minimally invasive transforaminal lumbar interbody fusion.

No study has examined the prognostic value of the Veterans RAND-12 (VR-12) Mental Component Score (MCS) on postoperative outcomes in minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) patients. This study examines the effect of preoperative VR-12 MCS on postoperative patient-reported outcome measures (PROMs) in MIS-TLIF patients. Patients were separated into 2 cohorts: VR-12 MCS < 50 and VR-12 MCS ≥ 50. PROMs of VR-12 MCS/Physical Component Score (PCS), Short Form-12 (SF-12) MCS/PCS, Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF), Patient Health Questionnaire-9 (PHQ-9), Visual Analog Scale (VAS) Back/Leg Pain (VAS-BP/LP), and Oswestry Disability Index (ODI) were collected.Of 329 patients, 151 were in the VR-12 MCS < 50 cohort. The VR-12 MCS < 50 cohort reported significantly inferior scores in all PROMs preoperatively, significantly inferior VR-12 MCS, SF-12 MCS, PROMIS-PF, PHQ-9, and ODI scores at 6-weeks postoperatively, and significantly inferior scores in all PROMs, except for VAS-BP at final follow-up. Magnitude of 6-week postoperative improvement was significantly greater in the VR-12 MCS < 50 cohort for VR-12 MCS, SF-12 MCS, and PHQ-9. Magnitude of final postoperative improvement was significantly greater in the VR-12 MCS < 50 cohort for VR-12 MCS, SF-12 MCS/PCS, and PHQ-9. MCID achievement rates were significantly greater in the VR-12 MCS < 50 cohort for VR-12 MCS, SF-12 MCS, and PHQ-9. MIS-TLIF patients with lesser preoperative VR-12 MCS reported inferior postoperative outcomes in mental health, physical function, pain, and disability. However, patients with inferior preoperative mental health reported greater rates of clinically meaningful improvement in mental health. Inferior preoperative mental health does not limit postoperative improvement in patients undergoing MIS-TLIF.

Preoperative motor weakness and the impact on patient reported outcomes in lateral lumbar interbody fusion.

This study measures the impact of preoperative motor weakness (MW) on Patient-Reported Outcome Measures (PROMs) in lateral lumbar interbody fusion (LLIF) patients. Retrospectively-sourced data from a prospectively-maintained, single-surgeon database created two cohorts of LLIF patients: patients with/without documented MW. Demographics/perioperative characteristics/PROMs were collected preoperatively and at six-weeks/final follow-up (FF). Studied outcomes were Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), 12-Item Short Form (SF-12) Physical/Mental Component Score (PCS/MCS), Patient Health Questionnaire (PHQ-9), Visual Analog Scale Back/Leg Pain (VAS-BP/LP), and Oswestry Disability Index (ODI). Multivariable linear/logistic regression calculated/compared intercohort minimum clinically important difference (MCID). Mean postoperative follow-up time was 11.5 ± 7.52 months. In total, 214 LLIF patients from December 2010 to May 2023 were included, with 149 having documented MW. In Table 1, self-reported gender was significant between cohorts (p < 0.025). Other significant demographic characteristics were smoker status (p < 0.002), diabetes (p < 0.016), and CCI score (p < 0.011). Table 2 shows notably significant perioperative characteristics: spinal pathology (degenerative spondylolisthesis/foraminal stenosis/herniated nucleus pulposus) (p < 0.005, all), estimated blood loss/length of stay/postoperative day (POD)-zero narcotic consumption (p < 0.001, all). Table 3 outcomes/MCID achievement percentages demonstrated insignificant intercohort differences besides a weakly significant FF ODI score (p < 0.036). MW, a frequently reported symptom in spine surgery, is poorly studied in LLIF patients. Thus, this study evaluates MW impact on PROMs and notes no significant differences. However, one exception regarding FF disability scores was recorded. MW did not affect MCID achievement for our patient population. Therefore, the preliminary findings suggest preoperative MW imparts minimal influence on PROMs/MCID in LLIF patients.

Severe Preoperative Disability Is Associated With Greater Mental Health Improvements Following Surgery for Degenerative Spondylolisthesis: A Cohort Matched Analysis.

OBJECTIVE: To evaluate preoperative disability's influence on patient-reported outcomes (PROs) following surgery for degenerative spondylolisthesis (DS). METHODS: DS patients who underwent surgical intervention were retrospectively identified from a single-surgeon spine registry. Cohorts based on Oswestry Disability Index (ODI) < 41 (milder disability) and ≥ 41 (severe disability) were created. Demographic differences were accounted for with 1:1 propensity score matching. For the matched sample, perioperative and PRO data were additionally collected. PROs assessed included mental health, physical function, pain, and disability. Pre- and up to 2-year postoperative PROs were utilized. Average time to final follow-up was 15.7 ± 8.8 months. Improvements in PROs and minimal clinically important difference (MCID) rates were calculated. Continuous variables were compared through Student t-test and categorical variables were compared through chi-square tests. RESULTS: Altogether, 214 patients were included with 77 in the milder disability group. The severe disability group had worse postoperative day (POD) 1 pain scores and longer hospital stays (p ≤ 0.038, both). The severe disability group reported worse outcomes pre- and postoperatively (p < 0.011, all), but had greater average improvement in 12-item Short Form health survey mental composite score (SF-12 MCS), 9-Item Patient Health Questionnaire (PHQ-9), visual analogue scale (VAS)-back, and ODI by 6 weeks (p ≤ 0.037, all) and PHQ-9, VAS-back and ODI by final follow-up (p ≤ 0.015, all). The severe disability cohort was more likely to achieve MCID for SF-12 MCS, PHQ-9, and ODI (p ≤ 0.003, all). CONCLUSION: Patients with greater baseline disability report higher POD 1 pain and discharge later than patients with milder disability. While these patients report inferior physical/mental health before and after surgery, they report greater improvements in mental health and disability postoperatively.

Utility of preoperative comorbidity burden on PROMIS outcomes after lumbar decompression: Cohort matched analysis.

The influence of Charlson Comorbidity Index (CCI) burden on Patient-Reported Outcomes Measurement Information System (PROMIS) outcomes following lumbar decompression (LD) is limited. The objective of this study is to evaluate CCI burden impact on PROMIS outcomes. Retrospective review of elective LD excluding revision or surgeries for infectious, malignant, or traumatic reasons. Demographics and PROMIS scores collected preoperatively and postoperatively up to 2 years included: PROMIS-Physical Function (PF)/Sleep Disturbance (SD)/Pain Interference (PI)/Anxiety (A), VR-12 Physical/Mental Health Composite scores (VR-12 PCS/MCS)/Oswestry Disability Index (ODI). Patients were divided into two groups based on their preoperative CCI score <3 (mild) or ≥4 (moderate to severe). Descriptive statistical analysis and MCID achievement rate calculations were conducted. A total of 182 patients were included: 93 CCI < 3 and 88 CCI ≥ 4. No significant differences were reported across preoperative PROMIS/legacy PROMs or final follow-up (p > 0.05, all). At 6-weeks, VR-12 PCS and ΔPROM scores indicated improved physician function in the CCI < 3 group (p = 0.020 and p = 0.040, respectively). Significant PROMIS-A ΔPROM score at final post-op was noted for CCI < 3 group (p = 0.026). MCID achievement demonstrated no significant differences for PROMIS outcomes and legacy PROMs. Results demonstrated that PROMIS outcomes were not impacted by a greater baseline comorbidity burden. At 6-weeks, the physical function scores were improved for the lower CCI group, and at final reported less anxiety. Our data suggests that comorbidity burden has a limited effect on PROMIS and legacy outcomes in patients undergoing LD.

Effect of Baseline Veterans RAND-12 Mental Composite Score on Postoperative Patient-Reported Outcome Measures for Cervical Disk Replacement.

STUDY DESIGN: Retrospective review. OBJECTIVE: To examine the effect of baseline Veterans RAND-12 (VR-12) Mental Composite Score (MCS) on clinical outcomes in patients undergoing cervical disk replacement (CDR) for herniated disk. BACKGROUND: Few studies in spine surgery have evaluated the impact of preoperative VR-12 MCS on postoperative outcomes in patients undergoing CDR. METHODS: Patients undergoing CDR for herniated disk were separated into 2 cohorts based on the VR-12 MCS standardized mean: VR-12 MCS<50 (worse mental health) and VR-12 MCS≥50 (better mental health). Patient-reported outcome measures of VR-12 MCS, VR-12 Physical Composite Score, Short Form-12 (SF-12) MCS, SF-12 Physical Composite Score, Patient-Reported Outcomes Measurement Information System Physical Function, Patient Health Questionnaire-9 (PHQ-9), Visual Analog Scale (VAS) Neck Pain, VAS Arm Pain, and Neck Disability Index were collected at preoperative and up to 2-year postoperative time points. RESULTS: In all, 109 patients were identified, with 50 patients in the worse mental health cohort. The worse mental health cohort reported inferior patient-reported outcome measures in all domains at preoperative, 6-week postoperative, and final postoperative time points. For 6-week postoperative improvement, the worse mental health cohort reported greater improvement for VR-12 MCS, SF-12 MCS, and PHQ-9. For final postoperative improvement, the worse mental health cohort reported greater improvement in VR-12 MCS and SF-12 MCS. Minimum clinically important difference achievement rates were higher in the worse mental health cohort for VR-12 MCS, SF-12 MCS, and PHQ-9. CONCLUSION: Patients undergoing cervical disk replacement for herniated disk with worse baseline mental health reported inferior clinical outcomes in mental health, physical function, pain, and disability outcomes throughout the postoperative period. Patients with worse baseline mental health demonstrated greater clinically meaningful improvement in mental health. In cervical disk replacement patients, those with worse baseline mental health may report inferior postoperative clinical outcomes but experience greater rates of tangible improvement in mental health.

Impact of Preoperative Symptom Duration on Patient-reported Outcomes After Minimally Invasive Transforaminal Interbody Fusion for Degenerative Spondylolisthesis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To assess the impact of preoperative symptom duration (PSD) on patient-reported outcome measures (PROMs) after minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF) for degenerative spondylolisthesis (DSpond). BACKGROUND: A prolonged duration of preoperative symptoms may implicate inferior long-term outcomes postsurgery. Prior studies of lumbar fusion recipients are limited by the inclusion of heterogeneous populations. METHODS: A single-surgeon registry was retrospectively queried for privately insured patients who had undergone primary, elective, single-level MIS-TLIF for DSpond with a recorded symptom start date. Cohorts were formed by PSD: shorter duration (PSD <1 y) or greater duration (GD; PSD ≥1 y). PROMs evaluated included Patient-reported Outcomes Measurement Information System-Physical Function, Oswestry Disability Index, Visual Analog Scale-Back, Visual Analog Scale-Leg, and 9-item Patient Health Questionnaire. The magnitude of PROM (∆PROM) improvement from preoperative baseline to 6 weeks and final follow-up (∆PROM-FF) were compared between cohorts. Intercohort achievement rates of a minimum clinically important difference in each PROM were compared. RESULTS: A total of 133 patients included 85 patients with GD cohort. There were no significant differences in pre hoc demographics and perioperative characteristics between cohorts, as well as preoperative, 6-week, or final follow-up PROMs between cohorts. Both cohorts demonstrated significant improvement in all PROMs at 6 weeks and final follow-up ( P ≤ 0.049, all). There were no significant intercohort differences demonstrated in minimum clinically important difference achievement rates, ∆PROM-6W, or ∆PROM-FF in any PROM. CONCLUSIONS: Regardless of the symptom duration before MIS-TLIF for DSpond, patients demonstrate significant improvement in physical function, pain, disability, and mental health. Patients with a GD of preoperative symptoms did not report inferior scores in any PROM domain. Patients with a GD of preoperative symptoms did not suffer inferior rates of clinically meaningful improvement after surgical intervention. These findings should be considered when counseling patients before surgical intervention for DSpond.

Obesity Does Not Negatively Affect Patient-perceived Outcomes After Cervical Disc Replacement for Disc Herniation.

STUDY DESIGN: Retrospective review. OBJECTIVE: To assess the impact of Body Mass Index (BMI) on patient-reported outcome measures (PROMs) after cervical disc replacement (CDR). BACKGROUND: BMI may affect PROMs after spine surgery. METHODS: Primary CDR recipients for herniated disc(s) with BMI <40 were retrospectively selected from a single-surgeon registry. Cohorts were divided into non-obese (BMI <30) and obese (BMI ≥30). Intercohort in-hospital complication rates were compared through independent samples t tests. Pre/postoperative PROMs were compared between cohorts through multivariable regression accounting for demographic differences. Final follow-up dates between patients averaged 11.8 ± 9.3 months. PROMs assessed included Patient-reported Outcomes Measurement Information System-Physical Function, Neck Disability Index, Visual Analog Scale-Neck, Visual Analog Scale-Arm, and the 9-item Patient Health Questionnaire. Improvements in PROMs were evaluated and compared at each follow-up within cohorts through paired t tests. The magnitude of improvement in PROMs from preoperative baseline at 6-week follow-up (∆PROM-6W) and final follow-up (∆PROM-FF) along with achievement rates of minimum clinically important differences were compared between cohorts through multivariable regression accounting for demographic differences. RESULTS: Of 153 patients, 53 patients were noted as obese. Demographic differences included age, prevalence of hypertension and diabetes, and comorbidity burden scores ( P ≤ 0.011, all). No significant variations in in-hospital complications were found. The non-obese cohort demonstrated improvements in all PROMs at 6 weeks and final follow-up periods ( P ≤ 0.005, all). The obese cohort demonstrated improvements in all postoperative PROMs besides 9-item Patient Health Questionnaire at 6 weeks ( P ≤ 0.015, all). After accounting for age and comorbidity variations, there were no significant intercohort differences in raw PROM scores, ∆PROM-6W, ∆PROM-FF, or minimum clinically important difference achievement rates. CONCLUSIONS: Regardless of BMI, patients experience significant improvements in physical function, disability, pain, and mental health after CDR for disc herniation. Patients with obesity do not suffer inferior patient-perceived outcomes after CDR. These findings may help surgeons counsel patients in the preoperative period.

Antibiotic use in spine surgery: A narrative review based in principles of antibiotic stewardship.

Background: A growing emphasis on antibiotic stewardship has led to extensive literature regarding antibiotic use in spine surgery for surgical prophylaxis and the treatment of spinal infections. Purpose: This article aims to review principles of antibiotic stewardship, evidence-based guidelines for surgical prophylaxis and ways to optimize antibiotics use in the treatment of spinal infections. Methods: A narrative review of several society guidelines and spine surgery literature was conducted. Results: Antibiotic stewardship in spine surgery requires multidisciplinary investment and consistent evaluation of antibiotic use for drug selection, dose, duration, drug-route, and de-escalation. Developing effective surgical prophylaxis regimens is a key strategy in reducing the burden of antibiotic resistance. For treatment of primary spinal infection, the diagnostic work-up is vital in tailoring effective antibiotic therapy. The future of antibiotics in spine surgery will be highly influenced by improving surgical technique and evidence regarding the role of bacteria in the pathogenesis of degenerative spinal pathology. Conclusions: Incorporating evidence-based guidelines into regular practice will serve to limit the development of resistance while preventing morbidity from spinal infection. Further research should be conducted to provide more evidence for surgical site infection prevention and treatment of spinal infections.

Effect of baseline veterans RAND-12 physical composite score on postoperative patient-reported outcome measures following lateral lumbar interbody fusion.

PURPOSE: To determine the prognostic value of preoperative Veterans RAND-12 (VR-12) Physical Composite Score (PCS) scores on postoperative clinical outcomes in patients undergoing lateral lumbar interbody fusion (LLIF). METHODS: LLIF patients were separated into 2 cohorts based on preoperative VR-12 PCS scores: VR-12 PCS < 30 (lesser physical function) and VR-12 PCS ≥ 30 (greater physical function). Patient-reported outcome measures (PROMs) of VR-12 PCS, VR-12 Mental Composite Score (MCS), Short Form-12 (SF-12) PCS, SF-12 MCS, Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), Patient Health Questionnaire-9 (PHQ-9), Visual Analog Scale (VAS) Back Pain (VAS-BP), VAS Leg Pain (VAS-LP), and Oswestry Disability Index (ODI) were collected at preoperative and up to 2-year postoperative time points. Mean postoperative follow-up time was 16.69 ± 8.53 months. Minimum clinically important difference (MCID) achievement was determined by comparing ∆PROM to previously established thresholds. RESULTS: Seventy-eight patients were included, with 38 patients with lesser preoperative physical function scores. Patients with lesser physical function reported significantly inferior preoperative PROM scores in all domains, except for SF-12 MCS and VAS-LP. At the 6-week postoperative time point, patients with lesser physical function reported significantly inferior VR-12 PCS, VR-12 MCS, SF-12 PCS, PROMIS-PF, and PHQ-9. At the final postoperative time point, patients with lesser physical function reported significantly inferior VR-12 PCS, VR-12 MCS, PROMIS-PF, PHQ-9, and ODI. Magnitude of 6-week postoperative improvement was significantly higher in the lesser physical function cohort for VR-12 PCS. CONCLUSION: Patients undergoing LLIF with worse baseline VR-12 PCS scores reported inferior postoperative physical function, mental health, and disability outcomes. At the final postoperative follow-up, magnitude of postoperative improvement and MCID achievement did not significantly differ. Baseline VR-12 PCS scores may indicate inferior postoperative clinical outcomes in physical function, mental health, and disability in patients undergoing LLIF; however, baseline VR-12 PCS does not limit the magnitude of postoperative improvement.

TRBV and TRBJ usage, when paired with specific HLA alleles, associates with distinct head and neck cancer survival rates.

Common or dominant, T-cell receptor (TCR), V and J usage, in combination with particular human leukocyte antigen (HLA) alleles, has been associated with differing outcomes in viral infections, autoimmunity, and more recently, in cancer. Cervical cancer in particular represents the most dramatic series of distinctions of outcomes associated with differing combinations of dominant V or J usage and HLA alleles, possibly because of the strong association of cervical cancer with human papilloma virus (HPV), in turn leading to a likely molecular consistency in the mechanism of HPV antigen presentation. Thus, we considered assessing TRB V and J usage, HLA allele combinations, for their associations with survival rates and related data, in the cancer genome atlas head and neck cancer dataset. We obtained the TRB VDJ recombination reads from both the blood and tumor exome files and determined the V and J identities. We then established case ID (patient) subsets of V or J usage, HLA alleles, and determined, for example, that the TRBJ2-7, HLA-B*40:01 combination was associated with a better disease free survival rate than were either the TRBJ1-3, HLA-DPB1*03:01 or the TRBJ2-1, HLA-DPB1*02:01 combinations. Furthermore, these analyses led to the conclusion that TRBJ1-5 usage, and the HLA-C*08:02 and HLA-DRB1*03:01 alleles, had independent associations with distinct overall survival rates. In sum, the results suggest that dominant V or J usage, HLA allele combinations, and in certain cases, dominant V or J usage independently of HLA, could be useful in prognosis and in guiding immunotherapies.

A scoring system for the electrostatic complementarities of T-cell receptors and cancer-mutant amino acids: multi-cancer analyses of associated survival rates.

The anti-tumor immune response is considered to be due to the T-cell receptor (TCR) binding to tumor antigens, which can be either wild-type, early stem cell proteins, presumably foreign to a developed immune system; or mutant peptides, foreign to the immune system because of a mutant amino acid (aa) or otherwise somatically altered aa sequence. Recently, very large numbers of TCR complementarity-determining region-3 (CDR3) aa sequences obtained from tumor specimens have become available. We developed a novel algorithm for assessing the complementarity of tumor mutant peptides and TCR CDR3s, based on the retrieval of TCR CDR3 aa sequences from both tumor specimen and patient blood exomes and by using an automated process of assessing CDR3 and mutant aa electrical charges. Results indicated many instances where high electrostatic complementarity was associated with a higher survival rate. In particular, our approach led to the identification of specific genes contributing significantly to the complementary, TCR CDR3-mutant aa. These results suggest a novel approach to tumor immunoscoring and may lead to the identification of high-priority neo-antigen, peptide vaccines; or to the identification of ex vivo stimulants of tumor-infiltrating lymphocytes.

T-cell receptor V and J usage paired with specific HLA alleles associates with distinct cervical cancer survival rates.

Cervical cancer is more strongly associated with a specific virus, Human Papilloma Virus (HPV), in otherwise healthy individuals, than is any other cancer. Thus, there is an expectation that an adaptive immune signature of cervical cancer would be highly apparent. Here we used a genomics approach to investigate the relationship between T-cell receptor (TCR) V and J usage and survival for patients diagnosed with cervical cancer, relying exclusively on tissue and blood exome files. Specific TCR V or J segments, identified in recombination reads recovered from the exome files, were combined with the patient HLA alleles to identify V or J, HLA allele combination groups associated with distinct survival rates. For examples, the T-cell receptor-ß (TRB) V6-5, HLA-A*02:01 combination was associated with a positive outcome, and the TRBV6-1, HLA-A*01:01 combination was associated with a negative outcome. Overall, these results point to V or J usage, HLA allele combinations as survival biomarkers, likely conveniently accessible with a noninvasive procedure, and the results may point the way towards immunological reagents useful in therapy designs.