Evaluating the success of an inpatient PA and NP program through trends in ED consults.

OBJECTIVE: We investigated the effect of an inpatient physician associate/assistant (PA) and NP program on consult volume, length of stay (LOS), and ED returns. METHODS: A retrospective observational study of 4,118 orthopedic ED consults was conducted from January 2017 to March 2022. Univariate statistics were used to evaluate outcomes between cohorts and multivariate regression to evaluate the odds of an LOS of less than 24 hours. RESULTS: After implementation of the PA and NP program, surgeon consults steadily declined and orthopedic consults increased markedly. Statistically significant differences were found in LOS of less than 24 hours and ED arrival-to-discharge time. Adjusting for case mix, patients were 47% more likely to be discharged within 24 hours. Survey results noted that more than 80% of surgeons felt on-call workload, disruptions to clinic and surgical schedules decreased, and quality of care increased. CONCLUSIONS: Implementation of an inpatient PA and NP program reduced orthopedic surgeon consults and hospital LOS while improving surgeon satisfaction with on-call workload, schedule disruptions, and quality of care.

Telemedicine Satisfaction and Preferences in an Orthopaedic Spine Clinic.

The use of telemedicine has expanded amid the COVID-19 pandemic and office closures and cancellation of elective surgeries early in the pandemic helped propagated its use. Previous studies have described the feasibility of telemedicine, however, little has been reported on patient perception and preferences within orthopaedics. The objective of this study was to evaluate satisfaction and preferences of telemedicine from the perspective of patients within an orthopaedic spine clinic. A cross-sectional, anonymous survey was implemented as a prospective quality improvement initiative. The survey was sent to patients who had an in-office or telemedicine visit with a provider in our orthopaedic spine clinic. Statistical analysis was performed on the results of the survey. The survey was sent to 1129 patients and a total of 316 patients responded. Twenty-one percent of respondents had a telemedicine appointment. There was no difference in satisfaction among groups (P = .288) and those with telemedicine appointments were more likely to have had a previous experience with this type of visit (P = .004) and were more inclined to use it in the future (P < .001). Patients preferred telemedicine because of the ability to get earlier appointments (P < .001) and the convenience of the visits (P < .001). Patients preferred in-office visits because they received hands-on physical exams (P = .003) or imaging (P = .041). Telemedicine is a viable alternative to in-office appointments for spine patients, as evidenced by similar levels of patient satisfaction. Sooner appointments and convenience are attractive elements of telemedicine visits, while the desire for physical examination remains a barrier to adoption in this population.

Wrist Fractures in Skiers and Snowboarders: Incidence, Severity, and Risk Factors Over 40 Seasons.

PURPOSE: To determine and compare the incidence and severity of wrist fractures in skiers and snowboarders. METHODS: A university-run orthopedic clinic at the base of a major ski resort has maintained an injury database spanning the years 1972 to 2012. Demographic information, equipment type, ability level, trail type and conditions, number of falls, circumstances surrounding the injury, and radiographs were collected on participants sustaining wrist fractures and compared with uninjured control participants asked the same questions, but in reference to their last fall where no injury resulted. A risk factor model for wrist fracture and severity in alpine sports was developed. RESULTS: During the 40-year period, 679 wrist fractures were identified. The incidence of wrist fracture per 1,000 days was 0.447 in snowboarders and 0.024 in skiers. In comparison with a representative sample of uninjured skiers, bivariate analyses revealed that skiers who experienced fractures were less experienced, had a greater number of falls, were on green or double black trails, and were injured owing to jumping or other reason related to technique. A higher risk for fracture was found for beginners, males younger than age 16, women older than age 50, and 4 or fewer days skiing that season. Bivariate analyses found that injured snowboarders were more likely to be female, younger, less experienced and had received less instruction than uninjured snowboarders. Higher risk for wrist fracture among snowboarders was found to be associated with age younger than 18 and less experience. CONCLUSIONS: Wrist fractures occur at an 18 times greater incidence in snowboarders than in skiers. Skiers with wrist fractures were beginners, males younger than 16, women older than 50, or those who had less participation. Snowboarders sustaining wrist fractures were younger than 18 or had less experience. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.

Addressing the Challenge of Spine Patient Triage: Development of a Simple Algorithm for Identification of Potential Surgical Candidates.

INTRODUCTION: Given that most spine conditions do not require surgical intervention, using surgeons to manage the subset of patients potentially requiring surgery is the most efficient resource allocation strategy. The purpose of this study was to develop a simple algorithm for identifying patients most likely to require spine surgery that could be used to appropriately triage this population to surgeons. METHODS: A retrospective review of 5,886 consecutive new patients presenting to a multidisciplinary spine clinic from March 2021 to September 2022 was conducted. The primary outcome was whether a patient underwent spine surgery during the study period. A total of 64 independent variables were recorded from patient intake and the first visit. A gradient boosted model was generated to identify the independent variables most associated with undergoing surgery. The five most important variables were entered into a multiple logistic regression model, and a simplified decision support tool was generated and assessed. RESULTS: Overall, 440 of 5886 patients (7.5%) underwent surgery during the study period. The following variables were identified as the top five predictors of spine surgery: patient goal of interest in learning about spine surgery, history of spine injections, difficulty walking a mile, radicular symptoms greater than axial symptoms, and increased age. Each of these variables was confirmed to be independently associated with undergoing surgery (all P < 0.001). The decision support tool yielded a sensitivity of 60.0%, specificity of 76.6%, likelihood ratio of 2.56, positive predictive value of 17.2%, and negative predictive value of 96.0% for predicting surgery. An AUC of 0.683 was achieved. CONCLUSION: A simple 5-question algorithm incorporating patient demographics, symptoms, treatment history, physical function, and patient goals may improve the ability of practices to identify potential spine surgery candidates before their first visit. Prospective application and evaluation of the algorithm to evaluate whether it improves the triage of appropriate patients to spine surgeons is warranted.

The Relationship Between Preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference and Pain Intensity Scores and Early Postoperative Pain and Opioid Consumption After Lumbar Fusion.

Background The Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference and pain intensity measures quantify separate dimensions of pain from the patient's perspective. This study aimed to assess differences in these outcomes and to evaluate whether baseline PROMIS pain scores could be used as a leading indicator of increased pain and opioid consumption during early recovery after lumbar fusion. Methods A retrospective review of 199 consecutive patients undergoing posterolateral fusion (PLF) at a single institution was performed. All patients underwent one to three level lumbar PLF and preoperatively completed the PROMIS pain intensity and PROMIS pain interference measures. Multivariate linear regression was used to assess the relationship between preoperative PROMIS scores and postoperative pain numeric rating scale (NRS) and oral morphine milligram equivalents (OMME) by day after controlling for age, sex, and body mass index (BMI). Results In comparison to patients with the lowest preoperative pain intensity scores, those with the highest scores required significantly more OMME on postoperative day (POD) zero and one (both p<0.05) and had higher pain NRS on POD one (p=0.02). Patients with the highest pain interference scores reported higher pain NRS on POD zero (p=0.02) but required similar OMME at all time points. After controlling for age, sex, and BMI, each one-point increase in preoperative PROMIS pain interference scores was associated with increased OMME on POD zero (ß=0.29, p=0.04) and POD one (ß=0.64, p=0.03). Conclusions Patients with high pain intensity reported higher levels of pain and required more opioids during the first 24 hours postoperatively, while those with high pain interference reported higher levels of pain on the day of surgery but utilized similar amounts of opioids. After risk adjustment, increased baseline PROMIS pain interference scores - but not pain intensity - were associated with increased opioid use. These results suggest that both measures should be considered when identifying patients at risk for increased pain and opioid consumption after PLF.

Disparities in Patient Reported Outcome Measure Completion Rates and Baseline Function in Newly Presenting Spine Patients.

STUDY DESIGN: Retrospective Review. OBJECTIVE: The purpose of this study was to evaluate disparities in patient reported outcome measures (PROM) completion rates and baseline function scores among newly presenting spine patients. SUMMARY OF BACKGROUND DATA: Prior studies have demonstrated that minority patients and those of low socioeconomic status may present with worse physical and mental health on PROMs. As PROMs are increasingly used in clinical care, research, and health policy, accurate assessment of health status among populations relies on the successful completion of PROM instruments. METHODS: A retrospective review of 10,803 consecutive new patients presenting to a single multidisciplinary spine clinic from June 2020 to September 2022 was performed. Univariate statistics were performed to compare demographics between patients who did and did not complete PROMs. Multivariable analysis was used to compare PROM instrument completion rates by race, ethnicity, and Social Vulnerability Index (SVI) and baseline scores among responders. RESULTS: 68.4% of patients completed PROMs at the first clinic visit. After adjusting for age, sex, body mass index, and diagnosis type, patients of non-white race (OR=0.661, 95%-CI=0.599-0.729, P<0.001), Hispanic ethnicity (OR=0.569, 95%-CI=0.448-0.721, P<0.001), and increased social vulnerability (OR=0.608, 95%-CI=0.511-0.723, P<0.001) were less likely to complete PROMs. In the multivariable models, patients of non-white race reported lower levels of physical function (ß=-6.5, 95%-CI=-12.4 to -0.6, P=0.032) and higher levels of pain intensity (ß=0.6, 95%-CI=0.2-1.0, P=0.005). Hispanic ethnicity (ß=1.5, 95%-CI=0.5-2.5, P=0.004) and increased social vulnerability (ß=1.1, 95%-CI=0.4-1.8, P=0.002) were each associated with increased pain intensity. CONCLUSION: Among newly presenting spine patients, those of non-white race, Hispanic ethnicity, and with increased social vulnerability were less likely to complete PROMs. As these subpopulations also reported worse physical function or pain intensity, additional strategies are needed to better capture patient reported health status in order to avoid bias in clinical care, outcomes research and health policy.

Preoperative Symptom Duration and the Effect on Clinical Outcomes and PROMIS-PF in Patients Undergoing Lumbar Fusion Surgery.

STUDY DESIGN: Retrospective Review. OBJECTIVE: The purpose of this study is to examine the effect of preoperative symptom duration on postoperative clinical outcomes for patients undergoing lumbar fusion surgery. SUMMARY OF BACKGROUND DATA: Lumbar fusion surgery can be significantly beneficial for lumbar spondylolisthesis and spinal stenosis. Surgical treatment is typically preceded by some amount of non-operative intervention and there isn't a consensus on the optimal timing between symptom onset and surgical intervention. METHODS: A retrospective review of 144 patients undergoing a 1-3 level lumbar fusion from June 2020 to December 2023 was performed. Demographics, preoperative symptom onset, primary diagnosis, and surgical procedure were compared between patients with less than or greater than 2 years of symptoms. Postoperative outcomes and PROMIS-PF were compared between groups. Univariate and multivariate analyses were performed. RESULTS: 52 (36.1%) had symptoms for 2 years or longer while 92 (63.9%) had symptoms for less than 2 years. There was no difference in demographics, procedure type, primary diagnosis, or preoperative symptoms between those who had symptoms for greater than or less than 2 years. Those who had symptoms for 2+ years had a significantly lower change in PF (4.7±7.1 vs. 7.7±9.0; P=0.029) and lower rate of MCID achievement (44.2% vs. 65.2%; P=0.023). There was no difference in outcomes by symptom duration. On multivariate analysis those with symptoms of 2 years or more were 2.4 times less likely to achieve an MCID (OR: 0.42, 95% CI: 0.19 to 0.92; P=0.031). CONCLUSION: Patients undergoing lumbar fusion with greater than 2 years of symptoms prior to surgery have a smaller increase in PROMIS-PF and are less likely to achieve MCID on PROMIS-PF. Further study is needed in order to determine the optimal timing for lumbar fusion surgery following symptom onset.

Does Surgical Day of Week Affect Patient Outcomes and Hospital Costs Following Lumbar Fusion?

Background As the population ages, surgical intervention for degenerative spine conditions is increasing, and this causes a commiserate increase in healthcare expenditures associated with these procedures. Little research has been done on the effect of early-week versus later-week surgeries on patient outcomes, cost, and length of stay (LOS) in patients undergoing lumbar fusion surgery. The purpose of this study is to compare LOS, patient outcomes, and hospital costs between patients having surgery early in the week and later in the week. Methods A retrospective review of 771 patients undergoing a one-, two-, or three-level lumbar fusion from December 2020 to December 2023 at a single institution was performed. Demographics, surgical details, postoperative outcomes and cost were compared between patients who had surgery on Monday, Tuesday, and Wednesday, to those having surgery Thursday or Friday. Univariate and multivariate analyses were performed to compare the groups. Results There were no differences in age, sex, BMI, race, American Society of Anesthesiology (ASA) scores, Charlson Comorbidity Index (CCI) scores, number of operative levels or inpatient/outpatient status between early- and late-week surgeries. Postoperatively the only significant difference was cost, late-week surgeries were, on average, $3,697 more expensive than early-week surgeries ($26,506 vs. $22,809; p<0.001). On multivariate analysis late-week surgeries were 2.47 times more likely to have a non-home discharge (OR: 2.47, 95% CI: 1.24 to 4.95; p=0.010) and 2.19 times more likely to have a 30-day readmission (OR: 2.19, 95% CI:1.01 to 4.74; p=0.044) Additionally, late-week surgeries were $2,041.55 (ß:2,041.55, 95% CI: 804.72 to 3,278.38; p=0.001) more expensive than early-week surgeries. Conclusions At our institution, patients undergoing one- to three-level lumbar fusion surgery on Thursday or Friday had a higher risk of non-home discharge, 30-day readmission, and incurred higher cost than those having early-week surgery. Further research is needed to elucidate the reasons for these findings and to evaluate interventions aimed at improving outcomes for patients undergoing surgery later in the week.

Outcomes in Lumbar Fusion Patients Stratified by the Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) Classification System.

Background and objective The Meyerding classification system remains the most common classification system for spondylolisthesis based on the percentages of vertebral translation. However, the majority of patients with degenerative disease fall into Grade 1, limiting its utility in this subset of patients. The Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) classification system provides a simple radiographic framework for classifying degenerative lumbar spondylolisthesis (DLS) patients by incorporating disc height, kyphosis, and anterior translation. The purpose of this study was to evaluate how clinical characteristics, treatments, and outcomes vary across different CARDS groups in patients undergoing one- or two-level lumbar fusion for DLS. Methods The patients were classified into one of the following four CARDS groups - Type A: advanced disc space collapse with no evidence of kyphosis; Type B: partially preserved disc space with less than 5.0 mm of translation; Type C: partially preserved disc space with greater than 5.0 mm of translation; and Type D: kyphotic alignment. Univariate analyses were performed to compare demographics, symptoms, clinical outcomes, and Patient-Reported Outcomes Measurement Information System (PROMIS) physical (PH) and mental health (MH) scores across groups. Results Ninety-one patients were included in the study. Based on the CARDS classification, there were three (3%) Type A patients, 25 (28%) Type B, 58 (64%) Type C, and five (5%) Type D. No significant differences in baseline demographics, symptom duration, or PROMIS scores were observed across groups. Interbody utilization varied, ranging from 19% in CARDS C (n=11) to 60% in CARDS B (n=15) and D (n=3) patients (p=0.005). Thirty-day clinical outcomes were similar across groups. At an average follow-up of 8.9 months, improvements in PROMIS PH and MH scores and rates of clinically significant improvement were similar across groups. Conclusions Based on our findings, patients undergoing lumbar fusion for DLS present with similar demographic and clinical characteristics and experience similar clinical and patient-reported outcomes when stratified using the CARDS classification system. Posterolateral fusion (PLF) can be effective for various radiographic presentations of DLS. Further research is warranted to assess the utility of CARDS in preoperative planning.

Are We Considering the Whole Patient? The Impact of Physical and Mental Health on the Outcomes of Spine Care.

STUDY DESIGN: Retrospective, observational. OBJECTIVE: To evaluate the influence of baseline health status on the physical and mental health (MH) outcomes of spine patients. SUMMARY OF BACKGROUND DATA: Spine conditions can have a significant burden on both the physical and MH of patients. To date, few studies have evaluated the outcomes of both dimensions of health, particularly in nonoperative populations. MATERIALS AND METHODS: At their first visit to a multidisciplinary spine clinic, 2668 nonoperative patients completed the Patient-reported Outcomes Measurement Information System-Global Health (PROMIS-GH) instrument and a questionnaire evaluating symptoms and goals of care. Patients were stratified by their baseline percentile score of the MH and physical health (PH) components of the PROMIS-GH. Four groups of patients were compared based on the presence or absence of bottom quartile PH or MH scores. The primary end point was the achievement of a minimal clinically important difference (MCID) on the MH or PH components at follow-up. Multivariate regression assessed the predictors of MCID achievement. RESULTS: After controlling for demographics, symptoms, and goals, each 1-point increase in baseline PROMIS-GH mental score reduced the odds of achieving MH MCID by 9.0% ( P <0.001). Conversely, each 1-point increase in baseline GH-physical score increased the odds of achieving MCID by 4.5% ( P =0.005). Each 1-point increase in baseline GH-physical score reduced the odds of achieving PH MCID by 12.5% ( P <0.001), whereas each 1-point increase in baseline GH-mental score increased the odds of achieving MCID by 5.0% ( P <0.001). CONCLUSIONS: Spine patients presenting with the lowest levels of physical or MH were most likely to experience clinically significant improvement in those domains. However, lower levels of physical or mental health made it less likely that patients would experience significant improvement in the alternative domain. Physicians should evaluate and address the complex spine population holistically to maximize improvement in both physical and mental health status.

Optimizing Patient Outcomes in Spinal Surgery: An Investigation Into Anesthesiologists' Case Volume.

Introduction Nearly one million patients in the United States undergo spine surgical procedures annually to seek relief from chronic back and neck pain. A multidisciplinary approach is key to ensuring the efficiency and safety of the surgical process, with the anesthesia team, nursing, surgeon, and healthcare facilities all playing a role. The purpose of this study is to capture potential associations between the anesthesiologists' case volume and patient postoperative outcomes in the early recovery period. Methods A retrospective review of anterior cervical discectomy and fusion (ACDF), lumbar decompression (LD), and lumbar fusion (LF) patients from July 2019 to June 2023 was performed. Anesthesiologists were categorized into low, medium, and high volumes of spine surgical cases. Univariate analysis was performed on patient demographics, intraoperative measures, post-anesthesia care unit (PACU) measures, and postoperative measures by anesthesiologist volume. Results This study included 545 ACDF, 815 LD, and 1,144 LF patients. There were no differences between groups in ACDF patients by anesthesiologist volume. When examining patients undergoing LD, there was a difference in patients with an American Society of Anesthesiologists (ASA) physical status classification of three or greater (low volume: 41.7% vs. medium volume: 53.7% vs. high volume: 45.0%; p=0.029). When examining patients undergoing LF, there were differences in patients with low temperatures in PACU (low volume: 2.8% vs. medium volume: 7.3% vs. high volume: 4.2%; p=0.044) and the percentage of patients with a 90-day emergency department return (low volume: 7.7% vs. medium volume: 11.9% vs. high volume: 7.0%; p=0.024). Conclusion While this study found a minimal impact of anesthesiologist volume on postoperative outcomes, recent literature has emphasized the critical role of teamwork and specialized surgical teams to enhance efficiency and patient care. Further studies are warranted to identify other variables in anesthesia, nursing, and surgical team workflow that may impact postoperative outcomes in spinal surgeries.

Effect of Lower Extremity Osteoarthritis on Outcomes of Lumbar Decompression.

BACKGROUND: The purpose of this study is to evaluate how hip or knee osteoarthritis (OA) and total joint arthroplasty impact the outcomes of patients undergoing lumbar decompression. METHODS: A retrospective review of 342 patients undergoing lumbar decompression without fusion from January 2019 and June 2021 at a single institution was performed. Univariate and multivariate analyses were used to compare outcomes between patients with and without concomitant hip or knee OA. RESULTS: Forty-six percent of patients had a hip or knee OA diagnosis and were higher risk as they were older, had higher BMIs, were more likely to be former smokers, had higher ASA scores, and were more likely to undergo 3+ level surgery. Postoperatively, after adjusting for differences between groups, hip or knee OA patients were more likely to be readmitted (OR=12.45, p=0.026) or have a complication (OR=13.77, p=0.031). However, patient reported outcomes as measured by Patient Reported Outcomes Measurement Information System-physical function. were similar at 1-3 months and 3-6 months. Higher levels of physical function were observed at 3-6 months postoperatively in hip OA patients with a history of THA. CONCLUSION: Patients with concomitant hip or knee OA are at higher risk for readmission and postoperative complications but may achieve similar levels of physical function as those without OA.

The Effect of Preoperative, Low-Dose Intrathecal Morphine on Patient Outcomes Following Lumbar Fusion Surgery: Can We Teach an Old Dog New Tricks?

BACKGROUND: Early pain control after lumbar fusion presents a challenge to patients and providers. Intrathecal morphine (ITM) has been used at the end of these procedures with limited benefit, but recent data suggest low-dose ITM at case initiation may be effective. This study aims to evaluate the use of preoperative ITM during lumbar fusion to determine whether there is a benefit for these patients. METHODS: One hundred and eighty lumbar fusion patients between 1 January 2018 and 31 May 2022 were evaluated. Patients were grouped by whether they received preoperative, low-dose ITM or not. Outcomes of interest included hospital narcotic consumption, pain scores, opioid-related complications, and complications within the first 90 days. RESULTS: Sixty-five study patients received 200 µg ITM at case initiation and 115 did not. No differences in length of stay, discharge disposition, or complications in the first 90 days were noted. ITM patients received fewer milligram morphine equivalents in the postanesthesia care unit (9.7 ± 31.23 vs 21.83 ± 21.07; P = 0.006) and on postoperative day 0 (18.60 ± 35.47 vs 35.47 ± 28.51; P = 0.001). Pain scores were lower in the ITM group both in the postanesthesia care unit and on postoperative day 0, with a decrease in extreme pain scores (>7; 35.4% vs 53.0%; P = 0.034). CONCLUSIONS: ITM appears to be safe and effective for reducing early pain and narcotic consumption on the day of surgery for lumbar fusion patients and may hold value for incorporation into rapid recovery protocols and for improving pain-related patient satisfaction. CLINICAL RELEVANCE: ITM appears to be safe and effective for reducing early pain and narcotic consumption on the day of surgery for lumbar fusion patients and may hold value for incorporation into rapid recovery protocols and for improving pain-related patient satisfaction.

Postoperative Outcomes in Patients Undergoing Orthopaedic Surgery Within 90 Days of Coronavirus Disease 2019.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) has resulted in a global pandemic with several hundred million infections worldwide. COVID-19 causes systemic complications that last beyond the initial infection. It is not known whether patients who undergo elective orthopaedic surgeries after COVID-19 are at increased risk of complications. The purpose of this study was to evaluate whether patients who undergo orthopaedic procedures after recent COVID-19 diagnosis are at increased risk of complications compared with those who have not had a recent COVID-19 diagnosis. METHODS: The TriNetX Research Network database was queried for patients undergoing elective orthopaedic surgeries from April 2020 to January 2022 in the following subspecialties: arthroscopic surgery, total joint arthroplasty, lumbar fusion, upper extremity surgery, foot and ankle (FA) surgery. Cohorts were defined by patients undergoing surgery with a diagnosis of COVID-19 from 7 to 90 days before surgery and those with no COVID-19 diagnosis 0 to 90 days before surgery. These cohorts were propensity-score matched based on differences in demographics and comorbidities. The matched cohorts were evaluated using measures of association analysis for complications, emergency department (ER) visits, and readmissions occurring 90 days postoperatively. RESULTS: Patients undergoing arthroscopic surgery were more likely to experience venous thromboembolism (VTE) ( P = 0.006), myocardial infarction ( P = 0.001), and ER visits ( P = 0.001). Patients undergoing total joint arthroplasty were more likely to experience VTE ( P < 0.001), myocardial infarction ( P < 0.001), pneumonia ( P < 0.001), and ER visits ( P = 0.037). Patients undergoing lumbar fusion were more likely to experience VTE ( P = 0.016), infection ( P < 0.001), pneumonia ( P < 0.001), and readmission ( P = 0.006). Patients undergoing upper extremity surgery were more likely to experience VTE ( P = 0.001) and pneumonia ( P = 0.015). Patients undergoing foot and ankle surgery were more likely to experience VTE ( P < 0.001) and pneumonia ( P < 0.001). CONCLUSION: There is an increased risk of complications in patients undergoing orthopaedic surgery after COVID-19 infection; all cohorts were at increased risk of VTE and most at increased risk of pneumonia. Additional investigation is needed to stratify the risk for individual patients.

Vitamin D in orthopaedics.

Vitamin D is an important component in musculoskeletal development, maintenance, and function. Adequate levels of vitamin D correlate with greater bone mineral density, lower rates of osteoporotic fractures, and improved neuromuscular function. Debate exists about both adequate levels required and intake requirements needed to prevent deficiency of vitamin D. Epidemiologic data have identified an increasing number of orthopaedic patients at risk for vitamin D deficiency, with potentially widespread consequences for bone healing, risk of fracture, and neuromuscular function.

Lower Extremity Osteoarthritis: A Risk Factor for Mental Health Disorders, Prolonged Opioid Use, and Increased Resource Utilization After Single-Level Lumbar Spinal Fusion.

INTRODUCTION: Few studies have examined the effect of hip or knee osteoarthritis, together described as lower extremity osteoarthritis (LEOA) on patient outcomes after lumbar fusion. The purpose of this study was to evaluate the effect of LEOA on postoperative outcomes and resource utilization in patients undergoing single-level lumbar fusion. METHODS: Using a national deidentified database, TriNetX, a retrospective observational study of 17,289 patients undergoing single-level lumbar fusion with or without a history of LEOA before September 1, 2019, was conducted. The no-LEOA and LEOA groups were propensity score matched, and 2-year outcomes were compared using univariate statistical analysis. RESULTS: After propensity score matching, 2289 patients with no differences in demographics or comorbidities remained in each group. No differences in the rate of repeat lumbar surgery were observed between groups (all P > 0.30). In comparison with patients with no LEOA, patients with LEOA experienced higher rates of overall and new onset depression or anxiety, prolonged opioid use, hospitalizations, emergency department visits, and ambulatory visits over the 2-year postoperative period (all P < 0.02). CONCLUSION: Patients with LEOA undergoing single-level lumbar fusion surgery are at higher risk for suboptimal outcomes and increased resource utilization postoperatively. This complex population may benefit from additional individualized education and multidisciplinary management.

The Impact of Depression and Anxiety on Perioperative Outcomes and Patient-Reported Outcomes Measurement Information System Physical Function After Thoracolumbar Surgery.

BACKGROUND: Depression and anxiety are common within spine patient populations. The demand for surgical management of degenerative spine conditions and the prevalence of mental disorders are expected to increase as the general population ages. Concurrently, there is increasing pressure to demonstrate high-value care through improved perioperative outcome metrics and patient-reported outcome instruments. The purpose of this study was to evaluate the impact of common mental disorders on perioperative markers of high resource utilization and patient-reported outcomes measurement information system physical function (PROMIS-PF) following thoracolumbar (TL) spine surgery. METHODS: A retrospective review of patients undergoing TL decompression alone or with fusion at a single institution. Data were collected using an administrative database for patient demographics. Outcomes of interest included length of stay, discharge disposition, 90-day return to the emergency department (ED), 90-day hospital readmission, 1-year complication rate, 1-year revision surgery rate, 1-year residual radiculopathy, and PROMIS-PF scores recorded preoperatively, at 0 to 1, 1 to 3, 3 to 6, and 6 to 12 months postoperatively. Univariate analysis and multiple linear regression were utilized to analyze results. RESULTS: A total of 596 patients were included in this study, of whom 205 (34%) had a history of depression or anxiety. Compared with patients with no history of a mental disorder, patients with depression or anxiety who underwent TL decompression alone had higher rates of 90-day ED visits (P = 0.019), 90-day readmissions (P = 0.031), and complications at 1 year (P = 0.012). After risk adjustment, the diagnosis of depression or anxiety had no significant effect on PROMIS-PF improvement from the preoperative to postoperative period. CONCLUSION: Our study suggests that a history of depression or anxiety is common among patients undergoing spine surgery but has no significant impact on PROMIS-PF improvement. Because some patients with depression or anxiety may be at higher risk of postoperative resource utilization, further study and effort are warranted to support at-risk groups and improve overall care value. CLINICAL RELEVANCE: Although patients with depression or anxiety are at risk for increased resource utilization after TL decompression or fusion, they can experience similar levels of functional improvement as patients without these conditions. Therefore depression or anxiety should not be considered contraindications to surgery, but additional attention should be paid to this population during the postoperative recovery period.

Development and validation of a risk-based algorithm for preoperative type and screen testing in spine surgery.

BACKGROUND CONTEXT: With improvements in surgical techniques and perioperative management, transfusion rates after spine surgery have decreased over time. Given this trend, routine preoperative ABO/Rh type and antibody screen (T&S) laboratory testing may not be warranted in all patients undergoing spine surgery. PURPOSE: The aim of the current study is to evaluate risk factors for intra/postoperative transfusion in patients undergoing a variety of spine procedures and to develop an algorithm for selectively ordering preoperative T&S testing in appropriate patients. STUDY DESIGN/SETTING: This is a single institution, retrospective observational study of patients undergoing emergent or elective spine surgery. External validation of the algorithm was performed on a national sample of patients undergoing spine surgery from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) national database. PATIENT SAMPLE: A total of 5,947 surgeries from January 1, 2016 to December 31, 2019 at a single institution, and 166,113 surgeries from the 2016 to 2018 ACS-NSQIP database. OUTCOME MEASURES: The primary outcome measure was performance of intraoperative or postoperative transfusion. METHODS: Using the institutional sample, univariate statistics (chi-square tests, fisher's exact test, 2-sided independent sample tests) were performed to compare demographics, comorbidities, and surgical details (case type, number of levels treated, etc.) between patients who did and did not require intra- or postoperative transfusion. Transfusion rates were calculated and compared across procedure types. Multivariate logistic regression was performed to identify independent predictors of transfusion and the model's accuracy was evaluated using the area under the curve (AUC) of the receiver operating characteristics (ROC) curve. A risk-based algorithm suggesting no preoperative T&S in low transfusion risk procedures, routine preoperative T&S in high-risk procedures, and further assessment in medium risk thoracolumbar fusion procedures was created. The algorithm's sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were evaluated when it was applied to both the institutional and national samples. Potential cost savings from reducing T&S orders were calculated. RESULTS: In the institutional sample, 120 patients (2.0%) required intraoperative or postoperative transfusion. The highest rates of transfusion were found in corpectomy (10.5%) and anterior/posterior cervical fusion (6.9%) procedures. In the multivariate logistic regression model, the presence of a preoperative coagulation defect or hemorrhagic condition (OR: 7.149, p<.001) and 6+ level surgery (OR: 7.511, p<.001) were the strongest predictors of transfusion. Overall, the model generated an AUC of 0.882, indicating excellent predictive accuracy. When applied to the institutional cohort, the risk-based algorithm had a sensitivity of 78.3%, specificity of 80.5%, PPV of 7.6%, and NPV of 99.4% for evaluating likelihood of transfusion. Using the algorithm 4,717 T&S tests would have been eliminated (79.3%), resulting in a cost savings of $179,246. Application of the model to the ACS-NSQIP cohort resulted in a sensitivity of 61.9%, specificity of 84.6%, PPV of 15.6%, and NPV of 98.0%. CONCLUSIONS: The routine use of preoperative ABO/Rh type and antibody screen testing does not appear to be warranted in patients undergoing spine surgery. A risk-based approach to preoperative type and screen testing may eliminate unnecessary tests and generate significant cost savings with minimal disruption to clinical care.

Social Determinants of Health Influence Early Outcomes Following Lumbar Spine Surgery.

Background: Disparities among social determinants of health (SDoH) can impact overall well-being and surgical outcomes. The purpose of this study was to identify SDoH for patients who underwent lumbar spine surgery and evaluate their relationship to the postoperative outcomes of length of stay (LOS), discharge disposition, and readmissions. Methods: We conducted a retrospective observational study of patients who underwent lumbar spine surgery from July 2017 to January 2021. We used a self-reported SDoH survey in conjunction with the electronic medical record to gather patient information. Multivariate analysis was used to evaluate the relationships between patient demographics, SDoH, and postoperative outcomes. Results: A total of 951 patients underwent lumbar spine surgery: 484 (50.9%) had decompressive laminectomy alone without fusion, and 467 (49.1%) had decompressive laminectomy with instrumented posterolateral fusion. When controlling for age, American Society of Anesthesiologists physical status classification, and surgery type, the SDoH of being currently married or having a life partner was associated with shorter LOS and decreased likelihood of discharge to a skilled nursing facility. Financial strain was associated with longer LOS, while attending church was associated with a decreased likelihood of 30-day emergency department (ED) return. Conclusion: This study identified various SDoH that may influence postoperative lumbar spine surgery outcomes of LOS, discharge disposition, 30-day ED return, and 30-day readmission. Patients at risk for suboptimal outcomes appear to be those with lower financial resources, less in-home support, and lower social connectivity. Routine screening of SDoH may enable care teams to effectively allocate resources for at-risk patients.

Structural Allograft Versus Synthetic Interbody Cage for Anterior Cervical Discectomy and Fusion: A Comparison of 1-Year Outcomes From a National Database.

STUDY DESIGN: Observational cohort study. OBJECTIVE: To compare 1-year perioperative complications between structural allograft (SA) and synthetic cage (SC) for anterior cervical discectomy and fusion (ACDF) using a national database. METHODS: The TriNetX Research Network was retrospectively queried. Patients undergoing initial single or multilevel ACDF surgery between October 1, 2015 and April 30, 2019 were propensity score matched based on age and comorbidities. The rates of 1-year revision ACDF surgery and reported diagnoses of pseudoarthrosis, surgical site infection (SSI), and dysphagia were compared between structural allograft and synthetic cage techniques. RESULTS: A comparison of 1-year outcomes between propensity score matched cohorts was conducted on 3056 patients undergoing single-level ACDF and 3510 patients undergoing multilevel ACDF. In single-level ACDF patients, there was no difference in 1-year revision ACDF surgery (P = .573), reported diagnoses of pseudoarthrosis (P = .413), SSI (P = .620), or dysphagia (P = .529) between SA and SC groups. In multilevel ACDF patients, there was a higher rate of revision surgery (SA 3.8% vs SC 7.3%, odds ratio = 1.982, P < .001) in the SC group, and a higher rate of dysphagia in the SA group (SA 15.9% vs SC 12.9%). CONCLUSION: While the overall revision and complication rate for single-level ACDF remains low despite interbody graft selection, SC implant selection may result in higher rates of revision surgery in multilevel procedures despite yielding lower rates of dysphagia. Further prospective study is warranted.