An Investment in Knowledge: Personal Finance Education for Medical Students.

The financial burden of pursuing a medical education continues to grow, with the average medical student now owing over $240,000 in total student loan debt by the time they graduate. This burden peaks at a time when trainees are making some of the most consequential decisions of their careers. Additionally, many students are simultaneously making important financial decisions related to personal aspirations, all before a drastic change in earning potential once they begin practicing as attending physicians. Medical trainees' financial stress is linked to specialty choice, mental quality of life, and physician burnout, with additional implications of such stress for patient health and safety.1- 3 Despite these issues, there are few examples of medical schools providing direct personal finance education to their students. Given the lack of personal finance education opportunities for medical students, the authors designed and implemented a medical student-specific personal finance curriculum at their home institution in conjunction with the Association of American Medical Colleges' (AAMC) Financial Information, Resources, Services, and Tools program. The curriculum, which is primarily delivered through interactive lectures, covers topics ranging from the basics of saving and investment to clinicians' potential future roles as administrators and innovators. The authors (1) present details regarding the creation of their personal finance education program; (2) invite fellow medical trainees and their respective institutions to start their own personal finance education programs or add similar curriculum to their health sciences coursework; and (3) call for recommendations by the American Medical Association (AMA) and AAMC in support of formal personal finance instruction for medical students on a national level.

The Effect of Diabetes and Metabolic Syndrome on Spine Surgery Outcomes.

PURPOSE OF REVIEW: Diabetes and metabolic syndrome are highly prevalent in patients undergoing spine surgery. This review aims to capture both the findings of recently published literature investigating the effects of diabetes and metabolic syndrome on spine surgery outcomes and the current best practices in patient management. RECENT FINDINGS: Diabetes and metabolic syndrome both contribute to worse outcomes in patients undergoing spine surgery. Although patients with diabetes are at greater risk of complications, those with uncontrolled diabetes experience increased healthcare costs and greater odds of postoperative complications. Furthermore, metabolic syndrome is repeatedly shown to have an adverse effect on spine surgery outcomes, including healthcare costs and medical complications. Spine surgeons should coordinate care with primary care physicians to optimize the preoperative profile of patients with comorbidities like diabetes and metabolic syndrome to minimize operative risk. With the shift to value-based care, understanding the patient factors that lead to complications is becoming increasingly important. Future studies should build upon the current literature and design preoperative interventions for at-risk patients. Additionally, further research is needed to analyze the modulatory effects of the social determinants of health in patients with diabetes and metabolic syndrome.

Impact of Social Determinants of Health in Spine Surgery.

PURPOSE OF REVIEW: Social determinants of health (SDH) are factors that affect patient health outcomes outside the hospital. SDH are "conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks." Current literature has shown SDH affecting patient reported outcomes in various specialties; however, there is a dearth in research relating spine surgery with SDH. The aim of this review article is to identify connections between SDH and post-operative outcomes in spine surgery. These are important, yet understudied predictors that can impact health outcomes and affect health equity. RECENT FINDINGS: Few studies have shown associations between SDH pillars (environment, race, healthcare, economic, and education) and spine surgery outcomes. The most notable relationships demonstrate increased disability, return to work time, and pain with lower income, education, environmental locations, healthcare status and/or provider. Despite these findings, there remains a significant lack of understanding between SDH and spine surgery. Our manuscript reviews the available literature comparing SDH with various spine conditions and surgeries. We organized our findings into the following narrative themes: 1) education, 2) geography, 3) race, 4) healthcare access, and 5) economics.

Predictive Analysis of Healthcare Resource Utilization after Elective Spine Surgery.

Introduction: The management of degenerative spine pathology continues to be a significant source of costs to the US healthcare system. Besides surgery, utilization of healthcare resources after spine surgery drives costs. The responsibility of managing costs is gradually shifting to patients and providers. Patient-centered predictors of healthcare utilization after elective spine surgery may identify targets for cost reduction and value creation. Therefore, our study aims to quantify patterns of healthcare utilization and identify risk factors that predict high healthcare utilization after elective spine surgery. Methods: A total of 623 patients who underwent elective spine surgery at a tertiary academic medical center by one of three fellowship-trained orthopedic spine surgeons between 2013 and 2018 were identified in this retrospective cohort study. Healthcare utilization was quantified including advanced spine imaging, emergency and urgent care visits, hospital readmission, reoperation, PT/OT referrals, opioid prescriptions, epidural steroid injections, and pain management referrals. Patient variables, namely, the Charlson comorbidity index (CCI) and the American Society of Anesthesiologists (ASA) classification system, were assessed as potential predictors for healthcare utilization. Results: Among all patients, a wide range of health utilization was identified. Age, body mass index, Charlson Comorbidity Index, and American Society of Anesthesiology class were identified as positive predictors of postoperative healthcare utilization including emergency department visits, spine imaging studies, opioid and nerve blocker prescriptions, inpatient rehabilitation, any referrals, and pain management referrals. Conclusions: Markers of patient health-such as CCI and ASA class-may be used to predict healthcare utilization following elective spine surgery. Identifying at-risk patients and addressing these challenges prior to surgery is an important step to deliver efficient postoperative care. Level of Evidence: 3.

Private Equity and Its Emergence in Orthopaedics.

Private equity (PE) is increasing its role in healthcare financing and may be a source of strategic funding for orthopaedic practice groups. With acquisitions in other medical specialties such as dermatology and ophthalmology, PE works to increase operating efficiency and cut costs. Orthopaedic practices' access to revenue through ancillary services and ambulatory surgery centers, coupled with a growing, aging cohort, make them an attractive candidate for PE acquisition. However, careful consideration is warranted before surgeons enter these partnerships to ensure patient safety, and the quality of care is not compromised because PE works to increase the return on their investment.

The content and accessibility of spine surgery fellowship websites and the North American Spine Surgery (NASS) fellowship directory.

BACKGROUND CONTEXT: The North American Spine Society (NASS) spine fellowship directory is an established resource that provides applicants with access to important information about different fellowship programs. Additionally, some programs have created websites to provide information about their fellowship program. There has been limited research on the amount and breadth of information provided by these different resources. PURPOSE: To assess and compare the scope of information provided by the North American Spine Society (NASS) fellowship directory and individual fellowship program websites. STUDY DESIGN/SETTING: Web Content Accessibility Study. PATIENT SAMPLE: There were no patient data used in this study. All reported data were accessed from public websites and the NASS fellowship directory (August 2022 fellowships). OUTCOME MEASURES: Outcome measures were reported as the presence or lack thereof of 22 topics pertaining to the specifics of each individual spine fellowship program on both the NASS fellowship directory and individual fellowship program websites. METHODS: The NASS fellowship directory (August 2022 fellowships) and individual program websites were evaluated by two independent reviewers. Program websites were identified via Google search with a systematic protocol. Within each platform, the availability of various data were recorded. Twenty-four different data points were assessed for each program and were categorized into four main categories-general program information, fellow profiles, clinical roles, and nonclinical roles of the fellow. Chi-squared tests were used to compare differences in the availability of specific data provided by the NASS fellowship directory and individual program websites. RESULTS: Seventy-four fellowship programs were identified. The NASS fellowship directory was more likely to provide information about the application process, a description of the program, fellow salary, faculty members, case descriptions, and research requirements (p<.05). The program websites were more likely to provide information about current and previous fellows-including a list of current fellow(s), their education/training, and a list of the previous fellows and their job choice (p<.05). Program websites were also more likely to discuss rotation schedules, clinic expectations, research opportunities, journal club, institutional meetings, sponsored national meetings, and current/previous research (p<.05). However, certain information, including specific clinical responsibilities (eg, rotation schedule, call expectations, clinic expectations) and the profiles of current and previous fellows, were not well represented on either platform. CONCLUSIONS: There were significant differences in the type of information provided by the NASS fellowship directory and program websites. Furthermore, there were key pieces of information that were not well represented on either platform.

Assessing the Early Impact of the COVID-19 Pandemic on Spine Surgery Fellowship Education.

STUDY DESIGN: This was a cross-sectional study. OBJECTIVE: The objective of this study is to report the impact of COVID-19 on spine surgery fellow education and readiness for practice. SUMMARY OF BACKGROUND DATA: COVID-19 has emerged as one of the most devastating global health crises of our time. To minimize transmission risk and to ensure availability of health resources, many hospitals have cancelled elective surgeries. There may be unintended consequences of this decision on the education and preparedness of current surgical trainees. MATERIALS AND METHODS: A multidimensional survey was created and distributed to all current AO Spine fellows and fellowship directors across the United States and Canada. RESULTS: Forty-five spine surgery fellows and 25 fellowship directors completed the survey. 62.2% of fellows reported >50% decrease in overall case volume since cancellation of elective surgeries. Mean hours worked per week decreased by 56.2%. Fellows reported completing a mean of 188.4±64.8 cases before the COVID-19 crisis and 84.1% expect at least an 11%-25% reduction in case volume compared with previous spine fellows. In all, 95.5% of fellows did not expect COVID-19 to impact their ability to complete fellowship. Only 2 directors were concerned about their fellows successfully completing fellowship; however, 32% of directors reported hearing concerns regarding preparedness from their fellows and 25% of fellows were concerned about job opportunities. CONCLUSIONS: COVID-19 has universally impacted work hours and case volume for spine surgery fellows set to complete fellowship in the middle of 2020. Nevertheless, spine surgery fellows generally feel ready to enter practice and are supported by the confidence of their fellowship directors. The survey highlights a number of opportunities for improvement and innovation in the future training of spine surgeons. LEVEL OF EVIDENCE: Level III.

Therapeutic Facet Joint Interventions in the Lumbar Spine: An Economic Value Perspective.

OBJECTIVE: In this narrative review, the current literature on therapeutic interventions for low back pain of facet joint etiology is assessed from an economic value perspective. SUMMARY OF BACKGROUND DATA: The efficacy and economics of facet joint interventions in the treatment of lumbar back pain is a controversial topic. Trends show that facet joint interventions are becoming increasingly used, perhaps as physicians become more averse to treating chronic low back pain with opioids. With the emphasis on value-based spine care and changing reimbursement models, the perspective of rigorously evaluating the outcomes these interventions provide and the costs they incur is particularly relevant. DISCUSSION: Although the evidence is noted to be limited, most systematic reviews fail to demonstrate the therapeutic utility of intra-articular facet joint injections in low back pain because of high study heterogeneity. A few good quality studies and systematic reviews describe moderate evidence for the utilization of therapeutic medial branch blocks and radiofrequency neurotomies in alleviating facet joint pain. CONCLUSION: Consequently, there is a need for high-quality cost-effectiveness studies for facet joint interventions so that evidence-based and economically viable solutions can be used to optimize patient care at a societally affordable price.

Burden of Sciatica on US Medicare Recipients.

OBJECTIVE: This study evaluates the disease burden of sciatica on the US Medicare cohort. BACKGROUND DATA: Sciatica is a common disability that has important physical, mental, and economic effects. The Medicare Health Outcomes Survey (HOS) is a demographic and outcomes survey used to monitor the performance of Medicare Advantage health plans in the United States. The HOS includes data on demographics, chronic medical conditions, and patient-reported outcomes. METHODS: Medicare HOS data for cohorts from 2007 to 2013 were obtained. Patients were placed into two categories based on the survey results: with or without a history of sciatica. Baseline demographics, chronic medical conditions, and physical health symptoms were aggregated. In addition, average VR-12 physical component summary and mental component summary scores were calculated for each group at baseline and at 2-year follow-up. A Fisher exact test was used to assess significance for categorical variables, and a t-test was used for continuous variables. VR-12 changes as small as 1 to 2 units have been found to be clinically and socially relevant. RESULTS: The baseline cohort data of 1,000,952 patients yielded 250,869 patients (25%) who reported the diagnosis of sciatica, compared with 750,083 patients (75%) without sciatica. Patients with a history of sciatica tended to be younger, less educated, and notably with more medical comorbidities. Physical component summary outcomes were approximately 8 units lower in the sciatica group at baseline and 7 units lower at 2-year follow-up. Mental component summary outcomes were 6 units lower in the sciatica group at baseline and 5 units lower at 2-year follow-up. CONCLUSION: A large percentage of the US Medicare cohort suffers from symptomatic sciatica. Our study identified a 25% prevalence in the Medicare cohort. In addition, sciatica is associated with an increased incidence of comorbid medical conditions and poor health-related quality of life. LEVEL OF EVIDENCE: Level III STUDY DESIGN:: Observational-Cohort Study.

Economic Value in Minimally Invasive Spine Surgery.

PURPOSE OF REVIEW: The field of spine surgery remains a unique target in the transition to value-based care. While spine surgery has benefited from new medical technologies, including minimally invasive surgery (MIS), these technologies may be a key driver in rising US healthcare costs. As such, MIS needs to clear an economic value threshold through a rigorous evaluation of the outcomes they provide and costs they incur. In this article, we review recent MIS surgery literature from the perspective of economic value. RECENT FINDINGS: Many studies report modest all-in cost savings and direct procedural cost equivalence for minimally invasive approaches relative to open surgeries. In terms of quality, studies found lower blood loss, length of stay, and infectious complications with MIS surgery but evidence on QALYs was mixed. In the past 5 years, there has been increasing research interest in defining economic value in MIS surgery. However, a significant amount of heterogeneity in research quality and methodology persists. Therefore, MIS surgery has the potential to be of high economic value, though this is not yet definitive. Future research should continue to focus on high-quality cost-effectiveness studies with clear methodologies to further elucidate economic value in MIS surgery.

A Financial Analysis of Procedural Revenue in Outpatient Spine Clinic: An Analysis of 36,312 Patient Appointments and Subsequent Surgeries at a Single Major Academic Institution.

OBJECTIVE: The economic pressures widely discussed in health care have a large impact on spine practices. This current study is the first to look at characteristics associated with revenues from an outpatient spine clinic. METHODS: All clinic visits to spine providers were identified at a single academic institution spanning the dates June 1, 2014, to June 1, 2018. All payment information was calculated using Medicare reimbursement values for Current Procedural Terminology codes. Relevant clinical, surgical, and cost structure data was collected for each patient. RESULTS: On average, providers had 21.9 average appointments over the course of 7.6 hours per clinic day. The average ratio of new to follow-up patients was 39.3%, with an average new patient to surgery conversion rate of 15.0%. The adjusted average total procedural revenue per new patient, controlled for scheduled appointment length and actual appointment length, was $686.02. The adjusted average procedural revenue per surgery was $3444.64 and average procedural revenue per hour in spine clinic was $552.40. With a 1% and 5% increase in new patient visits, total procedural revenue increases 2.7% and 13.5%, respectively. With a 1% and 5% increase in conversion rate, total procedural revenue increases 6.7% and 33.3%, respectively. With a decrease in new patient appointment length from 30 minutes to 25 minutes, the opportunity for 1.7 new patient appointments per day was created resulting in a net increase in procedural revenue per clinic day of $837.57. CONCLUSIONS: Incremental changes in practice structure can significantly affect procedural revenue. Significant heterogeneity also exists among spine providers.

Quantitative Risk Factor Analysis of Postoperative Dysphagia After Anterior Cervical Discectomy and Fusion (ACDF) Using the Eating Assessment Tool-10 (EAT-10).

STUDY DESIGN: A retrospective case series. OBJECTIVE: The aim of this study was to utilize the Eating Assessment Tool-10 (EAT-10) to quantitatively analyze risk factors contributing to dysphagia after anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: ACDF is one of the most common procedures performed in the United States, with postoperative dysphagia rates ranging from 2% to 60%. The EAT-10 is a self-administered, symptom-specific 10-item clinical instrument to document dysphagia symptom severity and has demonstrated excellent internal consistency, test-retest reliability, and criterion-based validity. METHODS: This study utilized a retrospective chart review of 163 patients from July 2013 to October 2017 who underwent ACDF at a single institution and prospectively completed EAT-10 surveys pre- and postoperatively. EAT-10 scores were collected preoperatively and at postoperative day 1, day 14, 1 month, 3 months, 6 months, and 12 months. Preselected risk factors were abstracted from the patients' chart. Univariate analyses were performed to identify candidate variables that correlated with abnormal EAT-10 scores at each time point. Multivariate logistic regression was then utilized to identify risk factors that were independently correlated with abnormal EAT-10 scores at each time point. RESULTS: Female gender, younger patients, and increased operating room (OR) time was associated with increased rates of dysphagia in the early postoperative period. History of obstructive sleep apnea, history of asthma, increased American Society of Anesthesiologists (ASA) score, and a larger number of spinal levels included in the surgery were correlated with increased dysphagia in the later postoperative periods. CONCLUSION: Dysphagia is common following ACDF. Factors associated with longer-term dysphagia seem to be more associated with pre-existing medical comorbidities. Understanding risk factors that correlate with increased rates of dysphagia has the potential to improve preoperative patient counseling and changes in operative management. LEVEL OF EVIDENCE: 4.

Factors Associated With Financial Relationships Between Spine Surgeons and Industry: An Analysis of the Open Payments Database.

STUDY DESIGN: A retrospective review of Centers for Medicare and Medicaid Services Database. OBJECTIVE: Utilizing Open Payments data, we aimed to determine the prevalence of industry payments to orthopedic and neurospine surgeons, report the magnitude of those relationships, and help outline the surgeon demographic factors associated with industry relationships. SUMMARY OF BACKGROUND DATA: Previous Open Payments data revealed that orthopedic surgeons receive the highest value of industry payments. No study has investigated the financial relationship between spine surgeons and industry using the most recent release of Open Payments data. METHODS: A database of 5898 spine surgeons in the United States was derived from the Open Payments website. Demographic data were collected, including the type of residency training, years of experience, practice setting, type of medical degree, place of training, gender, and region of practice. Multivariate generalized linear mixed models were utilized to determine the relationship between demographics and industry payments. RESULTS: A total of 5898 spine surgeons met inclusion criteria. About 91.6% of surgeons reported at least one financial relationship with industry. The median total value of payments was $994.07. Surgeons receiving over $1,000,000 from industry during the reporting period represented 6.6% of the database and accounted for 83.5% of the total value exchanged. Orthopedic training (P < 0.001), academic practice setting (P < 0.0001), male gender (P < 0.0001), and West or South region of practice (P < 0.0001) were associated with industry payments. Linear regression analysis revealed a strong inverse relationship between years of experience and number of payments from industry (r = -0.967, P < 0.0001). CONCLUSION: Financial relationships between spine surgeons and industry are highly prevalent. Surgeon demographics have a significant association with industry-surgeon financial relationships. Our reported value of payments did not include ownership or research payments and thus likely underestimates the magnitude of these financial relationships. LEVEL OF EVIDENCE: 3.

Dysphagia and Dysphonia Assessment Tools After Anterior Cervical Spine Surgery.

The Smith-Robinson approach to the anterior cervical spine is being increasingly used, but it is not without complication. Dysphagia and dysphonia are the most common complications of the procedure. Many classification systems have been developed to stage and grade postoperative dysphagia and dysphonia, but inconsistent usage and lack of consensus adoption has limited research progress. A discussion of the merits and limitations of the most common classification systems is outlined within this review. Broad adoption of comprehensive and simple classification metrics is needed, but, first, prospective reliability and validity must be established in the anterior cervical fusion population.

Preoperative predictors of increased hospital costs in elective anterior cervical fusions: a single-institution analysis of 1,082 patients.

BACKGROUND CONTEXT: The frequency of anterior cervical fusion (ACF) surgery and total hospital costs in spine surgery have substantially increased in the last several years. PURPOSE: To determine which patient comorbidities are associated with increased total hospital costs after elective one- or two-level ACFs. STUDY DESIGN/SETTING: Retrospective cohort analysis. PATIENT SAMPLE: Individuals who have undergone elective one- or two-level ACFs at our single institution. The total number of patients amounted to 1,082. OUTCOME MEASURES: Total hospital costs during single admission. METHODS: Multivariate linear regression models were used to analyze independent effects of preoperative patient characteristics on total hospital costs. Univariate analysis was used to examine association of these characteristics on operative time, length of hospital stay (LOS), and complications. RESULTS: Age, obesity, and diabetes were independently associated with increased average hospital costs of $1,404 (95% confidence interval [CI], $857-$1,951; p<.001), $681 (95% CI, $285-$1,076; p=.001), and $1,877 (95% CI, $726-$3,072; p=.001), respectively. Age was associated with increased LOS (p<.001) and complications (p<.001) but not operative time (p=.431). Diabetes was associated with increased LOS (p<.001) and complications (p=.042) but not operative time (p=.234). Obesity was not associated with increased LOS (p=.164), complications (p=.890), or operative time (p=.067). CONCLUSIONS: This study highlights the patient comorbidities associated with increased hospital costs after one- or two-level ACFs and the potential drivers of these costs.

Incidence and risk factors for postoperative ileus following anterior, posterior, and circumferential lumbar fusion.

BACKGROUND CONTEXT: Postoperative ileus is a known complication of surgery. The incidence and risk factors for ileus after lumbar fusion surgery is not well characterized. PURPOSE: To determine rates of postoperative ileus, a population-based database was analyzed to identify incidence, mortality, and risk factors associated with anterior (ALF), posterior (PLF), and combined anterior/posterior (APLF) lumbar fusions. STUDY DESIGN: This was a retrospective database analysis. PATIENT SAMPLE: The sample consisted of 220,522 patients from the Nationwide Inpatient Sample (NIS) database. OUTCOME MEASURES: Outcome measures were incidence of postoperative ileus, length of stay (LOS), in-hospital costs, and mortality. METHODS: Data from the NIS were obtained from 2002 to 2009. Patients undergoing ALF, PLF, and APLF for degenerative pathologies were identified and the incidence of postoperative ileus was assessed. Patient demographics, Charlson comorbidity index (CCI), LOS, costs, and mortality were assessed. SPSS v.20 was used to detect statistical differences between groups and perform logistic regression analyses to identify independent predictors of postoperative ileus. A p value less than .001 denoted significance. RESULTS: A total of 220,522 lumbar fusions were identified in the United States from 2002 to 2009. There were 19,762 ALFs, 182,801 PLFs, and 17,959 APLFs. The incidence of postoperative ileus was increased in ALFs over PLFs (74.9 vs. 26.0 per 1,000; p<.001). Within PLF and APLF groups, CCI scores were increased in the presence of postoperative ileus (p<.001). Across cohorts, patients with postoperative ileus demonstrated greater LOS and costs (p<.001). PLF-treated patients with postoperative ileus demonstrated increased mortality (p<.001). Independent predictors of postoperative ileus included male gender, 3+ fusion levels, alcohol abuse, anemia, fluid/electrolyte disorders, and weight loss (p<.001). CONCLUSIONS: The results of our study demonstrate increased incidence of postoperative ileus associated with anterior approaches for lumbar fusion. Across cohorts, postoperative ileus was associated with increased LOS and costs. To determine the mortality and resource use associated with postoperative ileus, we recommend preoperatively identifying and treating modifiable risk factors, especially when an anterior approach is used.

Cervical radiographical alignment: comprehensive assessment techniques and potential importance in cervical myelopathy.

STUDY DESIGN: Narrative review. OBJECTIVE: To provide a comprehensive narrative review of cervical alignment parameters, the methods for quantifying cervical alignment, normal cervical alignment values, and how alignment is associated with cervical deformity and myelopathy with discussions of health-related quality of life. SUMMARY OF BACKGROUND DATA: Indications for surgery to correct cervical alignment are not well-defined and there is no set standard to address the amount of correction to be achieved. In addition, classifications of cervical deformity have yet to be fully established and treatment options defined and clarified. METHODS: A survey of the cervical spine literature was conducted. RESULTS: New normative cervical alignment values from an asymptomatic volunteer population are introduced, updated methods for quantifying cervical alignment are discussed, and describing the relationship between cervical alignment, disability, and myelopathy are outlined. Specifically, methods used to quantify cervical alignment include cervical lordosis, cervical sagittal vertical axis, and horizontal gaze with the chin-brow vertical angle. Updated methods include T1 slope. Evidence from a few recent studies suggests correlations between radiographical parameters in the cervical spine and health-related quality of life. Analysis of the cervical regional alignment with respect to overall spinal pelvic alignment is emerging and critical. Cervical myelopathy and sagittal alignment of the cervical spine are closely related as cervical deformity can lead to spinal cord compression and tension. CONCLUSION: Cervical deformity correction should take on a comprehensive approach in assessing global cervical-pelvic relationships and the radiographical parameters that effect health-related quality of life scores are not well-defined. Cervical alignment may be important in assessment and treatment of cervical myelopathy. Future work should concentrate on correlation of cervical alignment parameters to disability scores and myelopathy outcomes. SUMMARY STATEMENTS: STATEMENT 1: Cervical sagittal alignment (cervical SVA and kyphosis) is related to thoracolumbar spinal pelvic alignment and to T1 slope. STATEMENT 2: When significant deformity is clinically or radiographically suspected, regional cervical and relative global spinal alignment should be evaluated preoperatively via standing 3-foot scoliosis X-rays for appropriate operative planning. STATEMENT 3: Cervical sagittal alignment (C2-C7 SVA) is correlated to regional disability, general health scores and to myelopathy severity. STATEMENT 4: When performing decompressive surgery for CSM, consideration should be given to correction of cervical kyphosis and cervical sagittal imbalance (C2-C7 SVA) when present.

Incidence and risk factors for dysphagia after anterior cervical fusion.

STUDY DESIGN: Retrospective database analysis. OBJECTIVE: To determine the national incidence, mortality, and risk factors for dysphagia associated with anterior cervical spinal fusion surgery in the United States. SUMMARY OF BACKGROUND DATA: Dysphagia is a known complication associated with anterior cervical fusion (ACF). A population-based database was analyzed to characterize the incidence of dysphagia in terms of demographics, mortality, and risk factors associated with ACF. METHODS: Data from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project were obtained from 2002 to 2009. Patients undergoing ACF for cervical myelopathy and/or radiculopathy were identified and separated into cohorts (1- to 2-level and 3+-level fusions), and incidences of dysphagia were identified. Demographics, length of stay, costs, mortality, and use of bone morphogenetic proteins (BMPs) were assessed. Statistical data were analyzed in SPSS (version 20), using the Student t test for discrete variables and the χ test for categorical data. Binomial logistic regression was used to identify independent predictors of dysphagia. A P value of less than 0.001 was used to denote significance. RESULTS: A total of 159,590 ACF cases were identified of which 139,434 were 1- to 2-level ACF and 20,156 were 3+-level ACF. The incidence of dysphagia in the 3+-level ACF group was double that of the 1- to 2-level ACF group (44.8 vs. 22.4 per 1000; P < 0.001). Patients with dysphagia were significantly older than patients without dysphagia (P < 0.001). Dysphagia was more common in males undergoing 1- to 2-level ACF (P < 0.001). BMP was used more frequently for patients with dysphagia in the 1- to 2-level ACF group (9.4% vs. 7.2% of cases; P < 0.001). Logistic regression analysis demonstrated that independent predictors for dysphagia included age (≥65 yr), male sex, 3+-level fusion, BMP use, and preoperative patient comorbidities. CONCLUSION: Dysphagia occurs twice as often after 3+-level ACF compared with 1- to 2-level ACF. Utilization of BMP was also linked to an increased incidence of dysphagia in the 1- to 2-level ACF group. Regardless of the number of levels fused, patients experiencing dysphagia had increased age, comorbid risk factors, hospitalizations, and costs. LEVEL OF EVIDENCE: 3.

Incidence and risk factors for postoperative delirium after lumbar spine surgery.

STUDY DESIGN: Retrospective database analysis. OBJECTIVE: A population-based database was analyzed to characterize the incidence, hospital costs, mortality, and risk factors associated with postoperative delirium after lumbar decompression (LD) and lumbar fusion (LF) surgical procedures. SUMMARY OF BACKGROUND DATA: Postoperative delirium is a common complication after surgery in the elderly that leads to increased hospitalization, cost, and other adverse outcomes. The incidence of delirium after lumbar spine surgery has not been discussed in this literature. METHODS: Data from the Nationwide Inpatient Sample were obtained from 2002-2009. Patients undergoing LD or LF for degenerative pathologies were identified. Patient demographics, comorbidities, length of stay, discharge disposition, costs, and mortality were assessed. SPSS version 20 was used for statistical analysis using independent T tests for discrete variables and χ2 tests for categorical data. Logistic regression was performed to identify independent predictors of delirium. A P value of less than 0.001 was used to denote significance. RESULTS: A total of 578,457 LDs and LFs were identified in the United States from 2002-2009. Of these, 292,177 were LDs and 286,280 were LFs. The overall incidence of delirium was 8.4 events per 1000 cases. Patients undergoing LF had a statistically greater incidence of delirium than patients undergoing LD (11.8 vs. 5.0 per 1000; P < 0.001). Patients experiencing delirium were significantly older and more likely to be female than nonaffected patients (P < 0.001). Patients with delirium in both cohorts demonstrated significantly greater comorbidities, length of stay, greater costs, and more frequent discharge to skilled nursing facilities (P < 0.001). The presence of delirium in LD-treated patients was associated with an increased mortality rate (6.1 vs. 0.8 per 1000; P < 0.001). Logistic regression demonstrated that independent predictors of delirium included older age (≥65 yr), alcohol/drug abuse, depression, psychotic disorders, neurological disorders, deficiency anemia, fluid/electrolyte disorders, and weight loss. CONCLUSION: The results of our study demonstrated an overall incidence of 8.4 events per 1000 lumbar spine surgical procedures. Overall analysis demonstrated an increased incidence of delirium in older females with greater comorbid conditions. Delirium was found to be associated with increased length of stay, costs, and mortality in all patients undergoing lumbar spine surgery. We recommend that physicians put greater effort into recognizing risk factors of delirium and diagnosing it in a timely manner to mitigate its effects. LEVEL OF EVIDENCE: 3.