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

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

A Longitudinal Evaluation of Coronavirus Disease 2019 and Its Effects on Spinal Decompressions With or Without Fusion.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: The objectives were to (1) compare the safety of spine surgery before and after the emergence of coronavirus disease 2019 (COVID-19) and (2) determine whether patients with a history of COVID-19 were at increased risk of adverse events. SUMMARY AND BACKGROUND DATA: The COVID-19 pandemic had a tremendous impact on several health care services. In spine surgery, elective cases were canceled and patients received delayed care due to the uncertainty of disease transmission and surgical outcomes. As new coronavirus variants arise, health care systems require guidance on how to provide optimal patient care to all those in need of our services. PATIENTS AND METHODS: A retrospective review of patients undergoing spine surgery between January 1, 2019 and June 30, 2021 was performed. Patients were split into pre-COVID or post-COVID cohorts based on local government guidelines. Inpatient complications, 90-day readmission, and 90-day mortality were compared between groups. Secondary analysis included multiple logistic regression to determine independent predictors of each outcome. RESULTS: A total of 2976 patients were included for analysis with 1701 patients designated as pre-COVID and 1275 as post-COVID. The pre-COVID cohort had fewer patients undergoing revision surgery (16.8% vs 21.9%, P < 0.001) and a lower home discharge rate (84.5% vs 88.2%, P = 0.008). Inpatient complication (9.9% vs 9.2%, P = 0.562), inpatient mortality (0.1% vs 0.2%, P = 0.193), 90-day readmission (3.4% vs 3.2%, P = 0.828), and 90-day mortality rates (0.8% vs 0.8%, P = 0.902) were similar between groups. Patients with positive COVID-19 tests before surgery had similar complication rates (7.7% vs 6.1%, P = 1.000) as those without a positive test documented. CONCLUSIONS: After the emergence of COVID-19, patients undergoing spine surgery had a greater number of medical comorbidities, but similar rates of inpatient complications, readmission, and mortality. Prior COVID-19 infection was not associated with an increased risk of postsurgical complications or mortality. LEVEL OF EVIDENCE: Level III.

Addressing the Impact of Race and Ethnicity on Musculoskeletal Spine Care in the United States.

➤ Despite being a social construct, race has an impact on outcomes in musculoskeletal spine care.➤ Race is associated with other social determinants of health that may predispose patients to worse outcomes.➤ The musculoskeletal spine literature is limited in its understanding of the causes of race-related outcome trends.➤ Efforts to mitigate race-related disparities in spine care require individual, institutional, and national initiatives.

Reference Managers.

Reference Managers (RMs) are software applications designed to build web-based libraries to organize, annotate, and reference literature when compiling a research study. With an ever-increasing volume of literature, RMs not only serve to centralize information but also allow seamless in-text citation and 1-click bibliography creation, with the ability to format each citation based on target journal specifications. There are many different RMs available for utilization; some of the most popular are EndNote, Zotero, Mendeley, and Paperpile. Each of these aforementioned applications has its own pros and cons, which this paper aims to summarize, though authors should take their individual research needs into consideration when deciding on their preferred reference manager.

Evidence-Based Medicine and Observational Studies.

Evidence-based medicine drives medical decision-making in the modern era, which has historically favored randomized control trials. Despite their notoriety, randomized control trials have multiple disadvantages when applied to spinal surgery. Observational studies are popular in spinal surgery literature and are seen in various forms, such as retrospective studies and prospective cohort studies. For researchers, learners, and practicing spine surgeons, this paper describes options for study design when applied to spinal surgery.

Techniques for Improving Electronic Survey Response Rate.

Electronic surveys are readily utilized for the conduction of orthopedic research and are commonly plagued by decreased response rates as compared with more conventional telephone and paper surveys. Given the rise of electronic survey usage and technological implementation into medical research, this paper aims to summarize factors both intrinsic and extrinsic which can increase survey completion in the clinical setting.

Reimbursement of Lumbar Fusion at an Orthopaedic Specialty Hospital Versus Tertiary Referral Center.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: To explore the differences in Medicare reimbursement for lumbar fusion performed at an orthopaedic specialty hospital (OSH) and a tertiary referral center and to elucidate drivers of Medicare reimbursement differences. SUMMARY OF BACKGROUND DATA: To provide more cost-efficient care, appropriately selected patients are increasingly being transitioned to OSHs for lumbar fusion procedures. There are no studies directly comparing reimbursement of lumbar fusion between tertiary referral centers (TRC) and OSHs. METHODS: Reimbursement data for a tertiary referral center and an orthopaedic specialty hospital were compiled through the Centers for Medicare and Medicaid Services. Any patient with lumbar fusions between January 2014 and December 2018 were identified. OSH patients were matched to TRC patients by demographic and surgical variables. Outcomes analyzed were reimbursement data, procedure data, 90-day complications and readmissions, operating room times, and length of stay (LOS). RESULTS: A total of 114 patients were included in the final cohort. The tertiary referral center had higher post-trigger ($13,554 vs. $8,541, P<0.001) and total episode ($49,973 vs. $43,512, P<0.010) reimbursements. Lumbar fusion performed at an OSH was predictive of shorter OR time (ß=0.77, P<0.001), shorter procedure time (ß=0.71, P<0.001), and shorter LOS (ß=0.53, P<0.001). There were no significant differences in complications (9.21% vs. 15.8%, P=0.353) or readmission rates (3.95% vs. 7.89%, P=0.374) between the 2 hospitals; however, our study is underpowered for complications and readmissions. CONCLUSION: Lumbar fusion performed at an OSH, compared with a tertiary referral center, is associated with significant Medicare cost savings, shorter perioperative times, decreased LOS, and decreased utilization of post-acute resources. LEVEL OF EVIDENCE: 3.

Does physical therapy impact clinical outcomes after lumbar decompression surgery?

Objectives: The objectives of our study were to (1) determine if physical therapy (PT) impacts patient-reported outcomes (PROMs) after lumbar decompression surgery and (2) determine if PT impacts postsurgical readmissions or reoperations after lumbar decompression surgery. Methods: Patients >18 years of age who underwent primary one- or two-level lumbar decompression at our institution were identified. Patient demographics, surgical characteristics, surgical outcomes (all-cause 90 days readmissions and 90 days surgical readmissions), and patient-reported outcomes (PROMs) were compared between the groups. Multivariate linear regression was utilized to determine the individual predictors of 90 days readmissions and PROMs at the 1-year postoperative point. Alpha was set at P < 0.05. Results: Of the 1003 patients included, 421 attended PT postoperatively. On univariate analysis, PT attendance did not significantly impact 90-day surgical reoperations (P = 0.225). Although bivariate analysis suggests that attendance of PT is associated with worse improvement in physical function (P = 0.041), increased preoperative Visual Analogue Scale leg pain (0 = 0.004), and disability (P = 0.006), as measured by the Oswestry Disability Index, our multivariate analysis, which accounts for confounding variables found there was no difference in PROM improvement and PT was not an independent predictor of 90-day all-cause readmissions (P = 0.06). Instead, Charlson Comorbidity Index (P = 0.025) and discharge to a skilled nursing facility (P = 0.013) independently predicted greater 90-day all-cause readmissions. Conclusions: Postoperative lumbar decompression PT attendance does not significantly affect clinical improvement, as measured by PROMs or surgical outcomes including all-cause 90 days readmissions and 90-day surgical readmissions.

A Novel Multimodal Postoperative Pain Protocol for 1- to 2-Level Open Lumbar Fusions: A Retrospective Cohort Study.

BACKGROUND: There has been increased interest in exploring methods to reduce postoperative pain without opioid medications. In 2015, a multimodal analgesia protocol was used involving the perioperative use of celecoxib, gabapentin, intravenous acetaminophen, lidocaine, and liposomal bupivacaine. Overall, the goal was to reduce the utilization of scheduled opioids in favor of nonopioid pain management. METHODS: The results of a consecutive series of 1- to 2-level open primary lumbar fusions were compared to a cohort of patients after the implementation the perioperative multimodal pain management protocol. Primary endpoints included patient-reported pain scores and secondary endpoints included length of stay. RESULTS: There were 87 patients in the preprotocol cohort and 184 in the protocol cohort. Comparing protocol and preprotocol patients, there were no significant differences in patient demographics. There was significantly average lower pain in the protocol group on postoperative day (POD) 1 (4.50 vs 5.00, P < 0.02) and POD2 (4.42 vs 5.50, P < 0.03). There was a lower pain score on POD0 (4.80 vs 5.00), but it was only clinically significant. There was a correlation between pain and duration of surgery in the preprotocol patients (POD0 R = 0.23, POD1 R = 0.02, POD2 R = 0.38), but not in the protocol patients (POD0 R = -0.05, POD1 R = -0.08, POD2 R = -0.04). There was a shorter length of stay in the protocol cohort (2.0 vs 3.0, P < 0.01). Finally, there was an approximately 35% reduction in morphine milligram equivalents of opioids in the protocol vs preprotocol cohorts (36.2 vs 57.0, P < 0.05). CONCLUSION: Our novel multimodal pain management protocol significantly reduced postoperative pain, length of stay, and opioid consumption in this patient cohort. Opioid usage correlated to pain in the protocol patients, while the preprotocol patients had no correlation between opioid use and pain medication. CLINICAL RELEVANCE: In this study, we demonstrated that preoperative and intraoperative analgesia can reduce postoperative pain medication requirements. Furthermore, we introduced a novel concept of a correlation of pain with opioid consumption as a marker of effective pain management of breakthrough pain.

The Impact of Unexpected Billing in Spine Surgery and How the Price Calculator Can Improve Patient Care.

STUDY DESIGN: Survey study. OBJECTIVE: The objective of this study was to determine the impact of unexpected in-network billing on the patient experience after spinal surgery. SUMMARY OF BACKGROUND DATA: The average American household faces difficulty paying unexpected medical bills. Although legislative efforts have targeted price transparency and rising costs, elective surgical costs continue to rise significantly. Patients are therefore sometimes still responsible for unexpected medical costs, the impact of which is unknown in spine surgery. METHODS: Patients who underwent elective spine surgery patients from January 2021 to January 2022 at a single institution were surveyed regarding their experience with the billing process. Demographic characteristics associated with unexpected billing situations, patient satisfaction, and financial distress, along with utilization and evaluation of the online price estimator, were collected. RESULTS: Of 818 survey participants, 183 (22.4%) received an unexpected in-network bill, and these patients were younger (56.7 vs. 63.4 y, P <0.001). Patients who received an unexpected bill were more likely to feel uninformed about billing (41.2% vs. 21.7%, P <0.001) and to report that billing impacted surgical satisfaction (53.8% vs. 19.1%, P <0.001). However, both groups reported similar satisfaction postoperatively (Likert >3/5: 86.0% vs. 85.5%, P =0.856). Only 35 (4.3%) patients knew of the price estimator's existence. The price estimator was reported to be very easy or easy (N=18, 78.2%) to understand and very accurate (N=6, 35.3%) or somewhat accurate (N=8, 47.1%) in predicting costs. CONCLUSIONS: Despite new regulations, a significant portion of patients received unexpected bills leading to financial distress and affecting their surgical experience. Although most patients were unaware of the price estimator, almost all patients who did know of it found it to be easy to use and accurate in cost prediction. Patients may benefit from targeted education efforts, including information on the price estimator to alleviate unexpected financial burden.

Reasons for transfer and subsequent outcomes among patients undergoing elective spine surgery at an orthopedic specialty hospital.

Objective: To evaluate the reasons for transfer as well as the 90-day outcomes of patients who were transferred from a high-volume orthopedic specialty hospital (OSH) following elective spine surgery. Materials and Methods: All patients admitted to a single OSH for elective spine surgery from 2014 to 2021 were retrospectively identified. Ninety-day complications, readmissions, revisions, and mortality events were collected and a 3:1 propensity match was conducted. Results: Thirty-five (1.5%) of 2351 spine patients were transferred, most commonly for arrhythmia (n = 7; 20%). Thirty-three transferred patients were matched to 99 who were not transferred, and groups had similar rates of complications (18.2% vs. 10.1%; P = 0.228), readmissions (3.0% vs. 4.0%; P = 1.000), and mortality (6.1% vs. 0%; P = 0.061). Conclusion: Overall, this study demonstrates a low transfer rate following spine surgery. Risk factors should continue to be optimized in order to decrease patient risks in the postoperative period at an OSH.

The Impact of Physical Therapy After Lumbar Fusion Surgery.

STUDY DESIGN: Retrospective Cohort. OBJECTIVE: To determine if outcomes varied between patients based on physical therapy (PT) attendance after lumbar fusion surgery. SUMMARY OF BACKGROUND DATA: The literature has been mixed regarding the efficacy of postoperative PT to improve disability and back pain, as measured by patient-reported outcome measures. Given the prevalence of PT referrals and lack of high-quality evidence, there is a need for additional studies investigating the efficacy of PT after lumbar fusion surgery to aid in developing robust clinical guidelines. METHODS: We retrospectively identified patients receiving lumbar fusion surgery by current procedural terminology codes and separated them into 2 groups based on whether PT was prescribed. Electronic medical records were reviewed for patient and surgical characteristics, PT utilization, and surgical outcomes. Patient-reported outcome measures (PROMs) were identified and compared preoperatively, at 90 days postoperatively and one year postoperatively. RESULTS: The two groups had similar patient characteristics and comorbidities and demonstrated no significant differences between readmission, complication, and revision rates after surgery. Patients that attended PT had significantly more fused levels (1.41 ± 0.64 vs. 1.32 ± 0.54, P =0.027), longer operative durations (234 ± 96.4 vs. 215 ± 86.1 min, P =0.012), and longer postoperative hospital stays (3.35 ± 1.68 vs. 3.00 ± 1.49 days, P =0.004). All groups improved similarly by Oswestry Disability Index, short form-12 physical and mental health subsets, and back and leg pain by Visual Analog Scale at 90-day and 1-year follow-up. CONCLUSION: Our data suggest that physical therapy does not significantly impact PROMs after lumbar fusion surgery. Given the lack of data suggesting clear benefit of PT after lumbar fusion, surgeons should consider more strict criteria when recommending physical therapy to their patients after lumbar fusion surgery. LEVEL OF EVIDENCE: Level-Ⅲ.

The Implication of Preoperative Central Stenosis on Patient-Reported Outcomes After Lumbar Decompression Surgery.

OBJECTIVE: To assess the impact of central stenosis severity on patient-reported outcomes after lumbar decompression. METHODS: Patient diagnosis, demographics, and surgical characteristics were collected via query search and manual chart review of electronic medical records. The inclusion criteria were posterior lumbar decompressions from 2014-2020, with accessible magnetic resonance imaging reports. As previously validated by Lee et al., central stenosis was determined on magnetic resonance imaging and graded as none, mild, moderate, or severe. Patients were dichotomized into 2 groups to improve statistical power for comparisons: none or mild central stenosis and moderate or severe central stenosis. Patient-reported outcome measures (PROMs) were compared between cohorts at 1 year postoperatively. Statistical significance was set at P < 0.05. RESULTS: On bivariate analysis, no significant differences were noted between cohorts with regard to preoperative, 1-year postoperative, and delta PROMs. In addition, no significant difference in the number of patients attaining minimal clinically important difference (MCID) for each PROM was noted between cohorts. With the exception of mental score of the Short Form-12 survey, all intragroup preoperative to postoperative PROMs indicated significant improvement (all P < 0.05) after lumbar decompression surgery. Multivariate regression identified moderate or severe central canal stenosis as a significant independent predictor of improvement in visual analog scale back (estimate = -1.464, P = 0.045). CONCLUSIONS: We demonstrate that patients with moderate or severe central spinal stenosis may have more improvement in back pain than those with mild or no central stenosis after lumbar spine decompression surgery.

Preoperative Opioid Prescribers and Lumbar Fusion: Their Effect on Clinical Outcomes and Postoperative Opioid Usage.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine the impact of multiple preoperative opioid prescribers on postoperative patient opioid usage and patient-reported outcome measures after single-level lumbar fusion. SUMMARY OF BACKGROUND DATA: Prior literature has identified opioid prescriptions from multiple postoperative providers increase opioid usage rates. However, there is limited evidence on how multiple preoperative opioid prescribers affect postoperative opioid usage or clinical outcomes after a single-level lumbar fusion. PATIENTS AND METHODS: A retrospective review of single-level transforaminal lumbar interbody fusion or posterolateral lumbar fusions between September 2017 and February 2020 at a single academic institution was performed. Patients were excluded if they were not identifiable in our state's prescription drug-monitoring program. Univariate comparisons and regression analyses identified factors associated with postoperative clinical outcomes and opioid usage. RESULTS: Of 239 patients, 160 (66.9%) had one or fewer preoperative prescribers and 79 (33.1%) had >1 prescribers. On regression analysis, the presence of multiple preoperative prescribers was an independent predictor of increased improvement in Visual Analog Scale (∆VAS) Back (ß=-1.61, P =0.012) and the involvement of a nonoperative spine provider was an independent predictor of increased improvement in ∆VAS Leg (ß = -1.53, P = 0.034). Multiple preoperative opioid prescribers correlated with an increase in opioid prescriptions postoperatively (ß = 0.26, P = 0.014), but it did not significantly affect the amount of morphine milligram equivalents prescribed (ß = -48.79, P = 0.146). A greater number of preoperative opioid prescriptions predicted worse improvements in VAS Back, VAS Leg, and Oswestry Disability Index and predicted increased postoperative opioid prescriptions, prescribers, and morphine milligram equivalents. CONCLUSIONS: Multiple preoperative opioid prescribers predicted increased improvement in postoperative back pain, whereas preoperative involvement of a nonoperative spine provider predicted improvements in leg pain after surgery. The number of preoperative opioid prescriptions was a better metric for predicting poor postoperative outcomes and increased opioid consumption compared with the number of preoperative opioid prescribers.

The Effect of Preoperative Exposure to Benzodiazepines on Opioid Consumption After One and Two-level Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: Investigate the relationship between preoperative benzodiazepine exposure and postoperative opioid use in patients undergoing primary 1 or 2-level anterior cervical discectomy and fusion (ACDF). BACKGROUND: Little is known about the effect of preoperative benzodiazepine exposure on postoperative opioid use in spine surgery. PATIENTS AND METHODS: Patients undergoing primary 1 or 2-level ACDF at a single institution from February 2020 to November 2021 were identified through electronic medical records. The prescription drug monitoring program was utilized to record the name, dosage, and quantity of preoperative benzodiazepines/opioids filled within 60 days before surgery and postoperative opioids 6 months after surgery. Patients were classified as benzodiazepine naïve or exposed according to preoperative usage, and postoperative opioid dose and duration were compared between groups. Regression analysis was performed for outcomes that demonstrated statistical significance, adjusting for preoperative opioid use, age, sex, and body mass index. RESULTS: Sixty-seven patients comprised the benzodiazepine-exposed group whereas 90 comprised the benzodiazepine-naïve group. There was no significant difference in average daily morphine milligram equivalents between groups (median: 96.0 vs 65.0, P = 0.11). The benzodiazepine-exposed group received postoperative opioids for a longer duration (median: 32.0 d vs 12.0 d, P = 0.004) with more prescriptions (median: 2.0 vs 1.0, P = 0.004) and a greater number of pills (median: 110.0 vs 59.0, P = 0.007). On regression analysis, preoperative benzodiazepine use was not significantly associated with postoperative opioid duration [incidence rate ratio (IRR): 0.93, P = 0.74], number of prescriptions (IRR: 1.21, P = 0.16), or number of pills (IRR: 0.89, P = 0.58). CONCLUSIONS: While preoperative benzodiazepine users undergoing primary 1 or 2-level ACDF received postoperative opioids for a longer duration compared with a benzodiazepine naïve cohort, preoperative benzodiazepine use did not independently contribute to this observation. These findings provide insight into the relationship between preoperative benzodiazepine use and postoperative opioid consumption. LEVEL OF EVIDENCE: Level III.

Creation of a Risk Calculator for Predicting New-Onset Cardiac Arrhythmias in Patients Undergoing Lumbar Fusion.

INTRODUCTION: As an increasing number of lumbar fusion procedures are being conducted at specialty hospitals and surgery centers, appropriate patient selection and risk stratification is critical to minimizing patient transfers. Postoperative cardiac arrhythmia has been linked to worse patient outcomes and is a common cause of patient transfer. Therefore, we created a risk calculator to predict a patient's likelihood of developing a new-onset postoperative cardiac arrhythmia after lumbar spinal fusion, which may improve preoperative facility selection. METHODS: A retrospective review was conducted of patients who undergoing lumbar fusion from 2017 to 2021 at a single academic center. Patients were excluded if they had any medical history of a cardiac arrhythmia. Multivariable regression was conducted to determine independent predictors of inpatient arrhythmias. The final regression was applied to a bootstrap to validate an arrhythmia prediction model. A risk calculator was created to determine a patient's risk of new-onset cardiac arrhythmia. RESULTS: A total of 1,622 patients were included, with 45 patients developing a new-onset postoperative arrhythmia. Age (OR = 1.05; 95% CI, 1.02 to 1.09; P = 0.003), history of beta-blocker use (OR = 2.01; 95% CI, 1.08 to 3.72; P = 0.027), and levels fused (OR = 1.59; 95% CI, 1.20 to 2.00; P = 0.001) were all independent predictors of having a new-onset inpatient arrhythmia. This multivariable regression produced an area under the curve of 0.742. The final regression was applied to a bootstrap prediction modeling technique to create a risk calculator including the male sex, age, body mass index, beta-blocker use, and levels fused (OR = 1.04, [CI = 1.03 to 1.06]) that produced an area under the curve of 0.733. CONCLUSION: A patient's likelihood of developing postoperative cardiac arrhythmias may be predicted by comorbid conditions and demographic factors including age, sex, body mass index, and beta-blocker use. Knowledge of these risk factors may improve appropriate selection of an outpatient surgical center or orthopaedic specialty hospital versus an inpatient hospital for lumbar fusions.

Patient-specific Risk Factors Increase Episode of Care Costs After Lumbar Decompression.

STUDY DESIGN: Retrospective cohort analysis. OBJECTIVE: To determine, which patient-specific risk factors increase total episode of care (EOC) costs in a population of Centers for Medicare and Medicaid Services beneficiaries undergoing lumbar decompression. SUMMARY OF BACKGROUND DATA: Lumbar decompression is an effective option for the treatment of central canal stenosis or radiculopathy in patients unresponsive to nonoperative management. Given that elderly Americans are more likely to have one or more chronic medical conditions, there is a need to determine, which, if any, patient-specific risk factors increase health care costs after lumbar decompression. METHODS: Care episodes limited to lumbar decompression surgeries were retrospectively reviewed on a Centers for Medicare and Medicaid Service reimbursement database at our academic institution between 2014 and 2019. The 90-day total EOC reimbursement payments were collected. Patient electronic medical records were then matched to the selected care episodes for the collection of patient demographics, medical comorbidities, surgical characteristics, and clinical outcomes. A stepwise multivariate linear regression model was developed to predict patient-specific risk factors that increased total EOC costs after lumbar decompression. Significance was set at P <0.05. RESULTS: A total of 226 patients were included for analysis. Risk factors associated with increased total EOC cost included increased age (per year) (ß = $324.70, P < 0.001), comorbid depression (ß = $4368.30, P = 0.037), revision procedures (ß = $6538.43, P =0.012), increased hospital length of stay (per day) (ß = $2995.43, P < 0.001), discharge to an inpatient rehabilitation facility (ß = $14,417.42, P = 0.001), incidence of a complication (ß = $8178.07, P < 0.001), and readmission (ß = $18,734.24, P < 0.001) within 90 days. CONCLUSIONS: Increased age, comorbid depression, revision decompression procedures, increased hospital length of stay, discharge to an inpatient rehabilitation facility, and incidence of a complication and readmission within 90 days were all associated with increased total episodes of care costs.

Clinical Improvements in Myelopathy Result in Improved Patient-Reported Outcomes Following Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine if myelopathy severity predicted the magnitude of improvement in health-related quality of life metrics following anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: Surgery for myelopathy is primarily performed to halt disease progression. However, it is still controversial if these patients can expect significant health-related quality-of life improvements following ACDF. We explore the relationship between modified Japanese Orthopaedic Association (mJOA) improvements and its effect on other health-related quality-of life metrics. MATERIALS AND METHODS: Patients undergoing ACDF for myelopathy were grouped based on preoperative mJOA scores into mild (15-17), moderate (12-14), and severe (<12) groups. Patients were subsequently categorized based on if they attained the minimum clinically detectable improvement (MCID) threshold for mJOA. Multivariate linear regression was performed to determine the magnitude of improvement in ∆patient-reported outcome measures. RESULTS: A total of 374 patients were identified for inclusion. Of those, 169 (45.2%) had mild myelopathy, 125 (33.4%) had moderate, and 80 (21.4%) had severe myelopathy. Only the moderate and severe groups had significant improvements in mJOA following surgery (mild: P =0.073, moderate: P <0.001, severe: P <0.001). There were no significant differences in the magnitude of improvement for any patient-reported outcome measure based on myelopathy severity, except for mJOA (mild: 0.27, moderate: 1.88, severe: 3.91; P <0.001). Patients meeting the MCID for mJOA had better ∆Short-Form 12 Mental Component Score (3.29 vs. -0.21, P =0.007), ∆Short-Form 12 Physical Component Score (6.82 vs. 1.96, P <0.001), ∆Visual Analog Scale Neck (-3.11 vs. -2.17, P =0.001), ∆Visual Analog Scale Arm (-2.92 vs. -1.48, P <0.001), ∆Neck Disability Index (-18.35 vs. -7.86, P <0.001), and ∆mJOA (3.38 vs. -0.56, P <0.001) compared with patients who did not. CONCLUSIONS: Worse baseline myelopathy severity predicts worse postoperative outcomes. However, baseline myelopathy severity is not predictive of the magnitude of postoperative improvement with the exception of mJOA. Patients who attain MCID improvement in mJOA had greater postoperative improvement for other health-related quality of life metrics.

Is disc height loss at 1 year predictive of pseudarthrosis and patient-reported outcome measures following anterior cervical discectomy and fusion with structural allograft?

OBJECTIVE: The authors sought to determine if postoperative disc height loss is associated with pseudarthrosis following anterior cervical discectomy and fusion (ACDF). They also sought to determine if the amount of postoperative disc height loss is predictive of need for revision for pseudarthrosis, as well as the impact of postoperative disc height loss on patient-reported outcome measures (PROMs) following surgery. METHODS: The authors retrospectively identified patients aged > 18 years who underwent primary one- to three-level ACDF with allograft at a single institution with 1-year postoperative lateral and flexion-extension cervical spine radiographs. Logistic regression models and receiver operating characteristic curves were used for analysis. Alpha was set at p < 0.05. RESULTS: Anterior or posterior disc height loss ≥ 2 mm was found in 52.5% of patients. Patients with a loss ≥ 2 mm were more likely to develop pseudarthrosis (p = 0.021) but not to undergo revision surgery due to pseudarthrosis (p = 0.459). Multivariable analysis identified male sex (OR 1.66, p = 0.013), the number of levels fused (OR 2.09, p < 0.001), and fusion at C6-7 (OR 1.52, p = 0.043) as predictors of disc height loss. The analysis also revealed that levels at the top (OR 0.383, 95% CI 0.170-0.854, p = 0.020) and middle (OR 0.174, 95% CI 0.053-0.548, p = 0.003) of fusion constructs were significant independent predictors of lower pseudarthrosis rates while disc height loss was not. Patients with disc height loss had significantly less improvement in scores for the Neck Disability Index (p = 0.002), visual analog scale (VAS) for arm pain (p = 0.018), and VAS for neck pain (p = 0.011) at 1 year following surgery. CONCLUSIONS: This study is, to the authors' knowledge, the largest study to date to assess the impact of postoperative disc height loss after ACDF. Disc height loss following ACDF was not predictive of revision surgery for pseudarthrosis or overall pseudarthrosis rates. However, pseudarthrosis was less likely to occur at the top and middle of fusion constructs. Loss in disc height postoperatively was significantly associated with less improvement in PROMs.

Effect of Drain Duration and Output on Perioperative Outcomes and Readmissions after Lumbar Spine Surgery.

STUDY DESIGN: Single-center retrospective cohort. PURPOSE: To compare surgical outcomes of patients based on lumbar drain variables relating to output and duration. OVERVIEW OF LITERATURE: The use of drains following lumbar spine surgery, specifically with respect to hospital readmission, postoperative hematoma, postoperative anemia, and surgical site infections, has been controversial. METHODS: Patients aged ≥18 years who underwent lumbar fusion with a postoperative drain between 2017 and 2020 were included and grouped based on hospital readmission status, last 8-hour drain output (<40 mL cutoff), or drain duration (2 days cutoff). Total output of all drains, total output of the primary drain, drain duration in days, drain output per day, last 8-hour output, penultimate 8-hour output, and last 8-hour delta (last 8-hour output subtracted by penultimate 8-hour output) were collected. Continuous and categorical data were compared between groups. Multivariate logistic regression analysis and receiver operating characteristic (ROC) analysis were performed to determine whether drain variables can predict hospital readmission, postoperative blood transfusions, and postoperative anemia. Alpha was 0.05. RESULTS: Our cohort consisted of 1,166 patients with 111 (9.5%) hospital readmissions. Results of regression analysis did not identify any of the drain variables as independent predictors of hospital readmission, postoperative blood transfusion, or postoperative anemia. ROC analysis demonstrated the drain variables to be poor predictors of hospital readmission, with the highest area under curve of 0.524 (drain duration), corresponding to a sensitivity of 61.3% and specificity of 49.9%. CONCLUSIONS: Drain output or duration did not affect readmission rates following lumbar spine surgery.