The role of electrical stimulation for rehabilitation and regeneration after spinal cord injury.

Electrical stimulation is used to elicit muscle contraction and can be utilized for neurorehabilitation following spinal cord injury when paired with voluntary motor training. This technology is now an important therapeutic intervention that results in improvement in motor function in patients with spinal cord injuries. The purpose of this review is to summarize the various forms of electrical stimulation technology that exist and their applications. Furthermore, this paper addresses the potential future of the technology.

Lymphadenopathy in Fungating Extremity Soft-Tissue Sarcoma: Metastasis or Reactive?

BACKGROUND: Patients with fungating extremity soft-tissue sarcoma (STS) can develop lymphadenopathy, which can represent nodal metastasis or benign reactive adenopathy. METHODS: In 1787 patients with STS, 67 (3.7%) had fungating extremity STS. In the 62 patients who met our inclusion criteria, we evaluated prevalence and histopathology of lymphadenopathy, factors associated with lymphadenopathy and nodal metastasis, and prevalence of and factors associated with lung metastasis and survival time from fungation. Logistic regression and Cox proportional-hazards models were used to analyze node pathology, lung metastasis, and survival duration with α = 0.05. RESULTS: Lymphadenopathy occurred in 11 of 62 patients (18%), 6 with nodal metastasis and 5 with reactive adenopathy. The only factor associated with lymphadenopathy was location of primary tumor in the upper extremity (p = 0.02). No tumor characteristics were associated with nodal metastasis. In all five patients with reactive adenopathy, the condition was recognized within 3 days after tumor fungation. Lymphadenopathy recognized more than 3 days after tumor fungation was likely to be nodal metastasis. Forty-one percent of patients developed lung metastasis, which was not associated with presence of lymphadenopathy or any patient or tumor characteristic. Age, tumor size, and Black and Asian race were independently associated with greater risk of death. CONCLUSIONS: Eighteen percent of patients with fungating extremity STS developed lymphadenopathy. Approximately half of cases represented nodal metastasis, and half represented reactive adenopathy. Lymphadenopathy that develops within 3 days after tumor fungation should increase suspicion for reactive adenopathy versus nodal metastasis.

Bibliometric Review of Medical Student Research Before Matching Integrated Vascular Surgery.

BACKGROUND: Research output is one element of a multifactorial process that residency programs consider when evaluating applicants. However, there are minimal data assessing research productivity on admittance into research-oriented integrated vascular surgery residency (RO-IVSR) programs. The purpose of this study was to evaluate the association of peer-reviewed research and the RO-IVSR match process. MATERIAL AND METHODS: Vascular surgery residents who matched into an RO-IVSR in 2015-2017 were divided into those matching an RO-IVSR top 10 program versus other. Total publications, first authorships, and type of research were compared between groups. Mann-Whitney U-tests were then performed between discrete levels of research productivity (0-1 versus ≥2 publications) to detect differences in ability to match a top 10 program. RESULTS: One hundred and fifty-eight residents published a total of 214 original research articles (83%), 26 case reports (10%), and 19 systematic reviews (7%). There were 66 first authorships (25%). Median total publications at RO-IVSR top 10 versus other programs were 2 versus 1 (P < 0.01). Top 10 IVSR had a significant difference in median publications for all other research categories. The ability to match into a top 10 program by discrete levels of research productivity at 0-1 versus 2+ showed significance (P < 0.05) in all research categories, including total publications, first authorships, and H-index. CONCLUSIONS: There was significantly higher research productivity among medical students who matriculate to top 10 IVSR programs. Furthermore, having 2 or more publications significantly increased the likelihood of attending a top 10 program. Thus, top programs likely use an applicants' research productivity as a distinct qualification category and a marker of future success.

Laryngoscopy Grade Improvement and Difficult Airway Resolution in Infants With Robin Sequence Undergoing Mandibular Distraction Osteogenesis: A Multi-Institutional Study.

OBJECTIVE: Mandibular distraction osteogenesis (MDO) aims to relieve tongue-based airway obstruction in Robin Sequence (RS). We investigated direct laryngoscopy grade (DLG) improvement and difficult airway (DA) resolution following MDO. DESIGN: Retrospective cohort analysis. SETTING: Three tertiary care institutions. PATIENTS: Sixty-four infants with RS who underwent a single MDO procedure in their first year of life were identified from January 2010 to January 2019. MAIN OUTCOME MEASURES: The primary outcome was DLG pre- and post-MDO. Secondary outcomes included DA designation, pre- and post-MDO polysomnographic assessment for obstructive sleep apnea (OSA), length of stay, need for gastrostomy, and major/minor adverse events. RESULTS: Median DLG improved from II pre-MDO to I at the time of distractor removal (n = 43, P < .001). No significant change was seen in patients with a third recorded time point (eg, palatoplasty; n = 78, P = .52). Twenty-six (47%) of 55 patients were designated as DA pre-MDO, and 10 (18%) of 55 patients retained the label post-MDO (P < .01). Five (50%) of these 10 patients appeared to be inappropriately retained. Median obstructive apnea-hypopnea index improved from 38.6 (range 31.2-62.8) pre-MDO to 2.9 (range 1-3.9) post-MDO (n = 12; P = .002). CONCLUSION: Mandibular distraction osteogenesis allowed for DLG improvement that was stably maintained as well as functional improvement in OSA, with minimal morbidity. Difficult airway designation persisted in the electronic record of some infants despite clinical resolution.

Infectious Complications After Open Cranial Vault Remodeling for Craniosynostosis.

BACKGROUND: Surgical site infection (SSI) after open cranial vault reconstruction (CVR), while relatively uncommon, has received little attention in the literature to date. Here, the authors report our institution's experience with the perioperative management of infectious complications following CVR for craniosynostosis and present the first systematic review of the literature on this topic. METHODS: The authors performed a retrospective chart review for patients with syndromic and nonsyndromic craniosynostosis who underwent open CVR between 1990 and 2015 at a single institution to determine predictors of SSIs and a systematic review of studies that evaluated for SSI after CVR to ascertain the pooled incidence of SSI, common infectious organisms, and prophylactic antibiotic protocols. RESULTS: Out of 548 primary and 163 secondary CVR cases at our institution, 6 primary reconstruction patients (1.09%) and 9 secondary reconstruction patients (5.52%) developed an SSI requiring extended hospital stay or readmission (P <0.001); overall infection rate was 2.11%. Streptococcus and Staphylococcus species were the most common organisms isolated. On multivariate analysis, syndromic status conferred more than 7 times greater odds of SSI (OR 7.7, P = 0.023). Pooled analysis of the literature yielded an overall SSI rate of 1.05% to 2.01%. In contrast to our institutional findings, the most common organisms reported were Candida species and Pseudomonas aeruginosa. The most common prophylactic antibiotic protocol was a first-generation cephalosporin for 24 to 72 hours post-operatively. CONCLUSIONS: Patients undergoing secondary reconstruction have higher infection rates after CVR, and syndromic status is an important predictor of infection when controlling for other patient factors. Our literature review reveals nosocomial organisms to be the most commonly reported source of infection, though this is contrary to our institutional findings of skin flora being most common. Antibiotic prophylaxis varies institutionally.

What Does it Mean to Be a #PlasticSurgeon? Analyzing Plastic Surgery Hashtag Utilization in Social Media.

BACKGROUND: The utilization of social media is growing among academic and private practice plastic surgeons. OBJECTIVES: The aim of this study was to determine training backgrounds and board certification of medical professionals through the use of plastic surgery-related hashtags on a single social media platform, Instagram. METHODS: Instagram was queried with 15 plastic surgery-related hashtags. Only the top 50 posts of each hashtag were analyzed at a single time point and international accounts were excluded. Data collected included account owner, degree, medical specialty, board certification, and type of post. RESULTS: The study sample consisted of 750 posts from an Instagram query in January 2019. Medical professionals accounted for 75% (n = 561) of posts. Board-certified physicians accounted for 56% (n = 420) of posts. Of the physician posters, 51% (n = 230) were trained in plastic surgery, 30% (n = 133) in otolaryngology, and 19% (n = 87) in other specialties. Facial rejuvenation content was more likely to be posted by otolaryngologists rather than plastic surgeons (P ≤ 0.001), whereas body-contouring procedures were more likely to be posted by plastic surgeons. Nonsurgical procedures and injectables were more likely to be posted by nonphysicians (P ≤ 0.001). Physicians without training in plastic surgery or otolaryngology were also more likely to post nonsurgical procedure-related hashtags (P ≤ 0.001). CONCLUSIONS: Medical professionals publish the majority of plastic surgery-related posts on Instagram; however, the utilization of plastic surgery hashtags by other specialties may be confusing or misleading to social media users who are unaware of interdisciplinary training differences.

Reduced-Intensity Haploidentical Bone Marrow Transplantation with Post-Transplant Cyclophosphamide for Solid Tumors in Pediatric and Young Adult Patients.

High-risk, recurrent, or refractory solid tumors in pediatric, adolescent, and young adult (AYA) patients have an extremely poor prognosis despite current intensive treatment regimens. We piloted an allogeneic bone marrow transplant platform using reduced-intensity conditioning (RIC) and partially HLA-mismatched (haploidentical) related donors for this population of pediatric and AYA solid tumor patients. Sixteen patients received fludarabine, cyclophosphamide, melphalan, and low-dose total body irradiation RIC haploidentical BMT (haploBMT) followed by post-transplantation cyclophosphamide (PTCy), mycophenolate mofetil, and sirolimus. All assessable patients were full donor chimeras on day 30 with a median neutrophil recovery of 19 days and platelet recovery of 21 days. One patient (7%) exhibited secondary graft failure associated with concomitant infection. The median follow-up time was 15 months. Overall survival was 88%, 56%, and 21% at 6, 12, and 24 months, respectively. Median survival from transplant date was 14 months with a median progression-free survival 7 months. We observed limited graft-versus-host disease in 3 patients and nonrelapse mortality in 1 patient. We demonstrated that RIC haploBMT with PTCy is feasible and has acceptable toxicities in patients with incurable pediatric and AYA solid tumors; thus, this approach serves as a platform for post-transplant strategies to prevent relapse and optimize progression-free survival.

Tumorigenicity of hypoxic respiring cancer cells revealed by a hypoxia-cell cycle dual reporter.

Although aerobic glycolysis provides an advantage in the hypoxic tumor microenvironment, some cancer cells can also respire via oxidative phosphorylation. These respiring ("non-Warburg") cells were previously thought not to play a key role in tumorigenesis and thus fell from favor in the literature. We sought to determine whether subpopulations of hypoxic cancer cells have different metabolic phenotypes and gene-expression profiles that could influence tumorigenicity and therapeutic response, and we therefore developed a dual fluorescent protein reporter, HypoxCR, that detects hypoxic [hypoxia-inducible factor (HIF) active] and/or cycling cells. Using HEK293T cells as a model, we identified four distinct hypoxic cell populations by flow cytometry. The non-HIF/noncycling cell population expressed a unique set of genes involved in mitochondrial function. Relative to the other subpopulations, these hypoxic "non-Warburg" cells had highest oxygen consumption rates and mitochondrial capacity consistent with increased mitochondrial respiration. We found that these respiring cells were unexpectedly tumorigenic, suggesting that continued respiration under limiting oxygen conditions may be required for tumorigenicity.

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.

Trends in Short Construct Lumbar Fusions Over the Past Decade at a Single Institution.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: (1) To compare the rates of fusion techniques over the last decade; (2) to identify whether surgeon experience affects a surgeon's preferred fusion technique; (3) to evaluate differences in complications, readmissions, mortality, and patient-reported outcomes measures (PROMs) based on fusion technique. SUMMARY OF BACKGROUND DATA: Database studies indicate the number of lumbar fusions have been steadily increasing over the last two decades; however, insufficient granularity exists to detect if surgeons' preferences are altered based on additive surgical experience. METHODS: A retrospective review of continuously collected patients undergoing lumbar fusion at a single urban academic center was performed. Rates of lumbar fusion technique: posterolateral decompression fusion (PLDF), transforaminal lumbar interbody fusion (TLIF), anterior lumbar interbody fusion + PLDF (ALIF), and lateral lumbar interbody fusion + PLDF (LLIF) were recorded. Inpatient complications, 90-day readmission, and inpatient mortality were compared with χ 2 test and Bonferroni correction. The Δ 1-year PROMs were compared with the analysis of variance. RESULTS: Of 3938 lumbar fusions, 1647 (41.8%) were PLDFs, 1356 (34.4%) were TLIFs, 885 (21.7%) were ALIFs, and 80 (2.0%) were lateral lumbar interbody fusions. Lumbar fusion rates increased but interbody fusion rates (2012: 57.3%; 2019: 57.6%) were stable across the study period. Surgeons with <10 years of experience performed more PLDFs and less ALIFs, whereas surgeons with >10 years' experience used ALIFs, TLIFs, and PLDFs at similar rates. Patients were more likely to be discharged home over the course of the decade (2012: 78.4%; 2019: 83.8%, P <0.001). No differences were observed between the techniques in regard to inpatient mortality ( P =0.441) or Δ (postoperative minus preoperative) PROMs. CONCLUSIONS: Preferred lumbar fusion technique varies by surgeon preference, but typically remains stable over the course of a decade. The preferred fusion technique did not correlate with differences in PROMs, inpatient mortality, and patient complication rates. LEVELS OF EVIDENCE: 3-treatment.

Revision lumbar fusions have higher rates of reoperation and result in worse clinical outcomes compared to primary lumbar fusions.

BACKGROUND CONTEXT: Indications for revision lumbar fusion are variable, but include recurrent stenosis (RS), adjacent segment disease (ASD), and pseudarthrosis. The efficacy of revision lumbar fusion has been well established, but their outcomes compared to primary procedures is not well documented. PURPOSE: The purpose of this study was to compares surgical and clinical outcomes between (1) revision and primary lumbar fusion, (2) revision lumbar fusion based on indication (ASD, pseudarthrosis, or RS), and (3) revision lumbar fusion based on whether the index procedure included an isolated decompression or decompression with fusion. STUDY DESIGN/SETTING: Retrospective single-institution cohort study. PATIENT SAMPLE: Four thousand six hundred seventy-one consecutive lumbar fusions from 2011 to 2021, of which 892 (23.6%) were revision procedures. The indication for revision procedures included 502 (56.3%) for ASD, 153 (17.2%) for pseudarthrosis, and 237 (26.6%) for RS. Of the 892 revision procedures, 694 (77.8%) underwent an index fusion while 198 (22.2%) underwent an index decompression without fusion. OUTCOME MEASURES: Hospital readmissions, all-cause reoperation, need for subsequent revision and patient reported outcome measures (PROMs) at baseline, 3-months postoperatively, and 1-year postoperatively, including the Mental Health Component score (MCS-12) and Physical Health Component score (PCS-12) of the Short Form 12 survey, the Oswestry Disability Index (ODI), and the Visual Analog Scale (VAS) for Back and Leg pain. METHODS: Patient demographics, comorbidities, surgical characteristics, and outcomes were collected from electronic medical records. Twenty-eight percent of patients had preoperative and postoperative PROMs. A delta PROM score was calculated for the 3-month and 1-year postoperative timepoints, which was the change from the preoperative to postoperative value. Univariate comparisons were performed to compare revision fusions to primary fusions. Multivariate logistic regression was performed for all-cause reoperation and subsequent revision surgery, while multivariate linear regression was performed for ∆PROMs at 3-months and 1-year. Revision procedures were then separately regrouped based on indication for revision fusion and whether they underwent a fusion for their index procedure. Univariate comparisons and multivariate linear regressions for ∆PROMs were then repeated based on the new groupings. RESULTS: There was no difference in hospital readmission rate (5.38% vs. 4.60%, p=.372) or length of stay (4.10 days vs. 3.94 days, p=.129) between revision and primary lumbar fusion, but revision fusions had a higher rate of all-cause reoperation (16.1% vs. 11.2%, p<.001) and subsequent revision (13.7% vs. 9.71%, p=.001), which was confirmed on multivariate logistic regression (Odds Ratio (OR): 1.42, p=.001 and OR: 1.37, p=.007, respectively). On multivariate analysis, a revision procedure was an independent risk factor for worse improvement ∆ODI, ∆VAS Back, ∆VAS Leg, and ∆PCS-12 and 1-year postoperatively. Regardless of the indication for revision lumbar fusion, patients significantly improved in the 3-month and 1-year postoperative PCS-12, ODI, VAS Back, and VAS Leg, with the exception of the 3-month PCS-12 for pseudarthrosis (p=.620). Patients undergoing revision for ASD had significantly worse 1-year postoperative PCS-12 (32.3 vs. Pseudarthrosis: 35.6 and RS: 37.0, p=.026), but there were no differences in ∆PROMs. There was no difference in hospital readmission, all-cause reoperation, or subsequent revision based on whether a patient had an index lumbar fusion or isolated decompression. Multivariate linear regression analysis found that a surgical indication of pseudarthrosis was a significant predictor of decreased improvement in 3-month ∆VAS Leg (ref: ASD, ß=2.26, p=.036), but having an index fusion did not significantly predict worse improvement in ∆PROMs when compared to isolated decompressions. CONCLUSIONS: Revision lumbar fusions had a higher rate of reoperation and subsequent revision surgery when compared to primary lumbar fusions, but there were no difference in hospital readmission rates. Patients undergoing revision lumbar fusion experience improvements in all patient reported outcome measures, but their baseline, postoperative, and magnitude of improvement are worse than primary procedures. Regardless of whether the lumbar fusion is a primary or revision procedure, all patients have significant improvements in pain, disability and physical function. Further, the indication for the revision procedure is not correlated with the expected magnitude of improvement in patient reported outcomes. Finally, no differences in baseline, postoperative, and ∆PROMs for revision fusions were identified when stratifying by whether the patient had an index decompression or fusion.

Incidence, Risk Factors, and Outcomes of Incidental Durotomy during Lumbar Spine Decompression with or without Fusion.

STUDY DESIGN: Retrospective cohort study. PURPOSE: The primary objective of this study was to determine the incidence and risk factors for incidental durotomies during lumbar decompression surgeries. In addition, we aimed to determine the changes in patient-reported outcome measures (PROMs) based on incidental durotomy status. OVERVIEW OF LITERATURE: There is limited literature investigating the affect of incidental durotomy on patient reported outcome measures. While the majority of research does not suggest differences in complications, readmission, or revision rates, many studies rely on public databases, and their sensitivity and specificity for identifying incidental durotomies is unknown. METHODS: Patients undergoing lumbar decompression with or without fusion at a single tertiary care center were grouped based on the presence of a durotomy. Multivariate analysis was performed for length of stay (LOS), hospital readmissions, and changes in PROMs. To identify surgical risk factors for durotomy, 3:1 propensity matching was performed using stepwise logistic regression. The sensitivity and specificity of the International Classification of Disease, 10th revision (ICD-10) codes (G96.11 and G97.41) were also assessed. RESULTS: Of the 3,684 consecutive patients who underwent lumbar decompressions, 533 (14.5%) had durotomies, and a complete set of PROMs (preoperative and 1-year postoperative) were available for 737 patients (20.0%). Incidental durotomy was an independent predictor of increased LOS but not hospital readmission or worse PROMs. The durotomy repair method was not associated with hospital readmission or LOS. However, repair with collagen graft and suture predicted reduced improvement in Visual Analog Scale back (ß =2.56, p=0.004). Independent risk factors for incidental durotomies included revisions (odds ratio [OR], 1.73; p<0.001), levels decompressed (OR, 1.11; p=0.005), and preoperative diagnosis of spondylolisthesis or thoracolumbar kyphosis. The sensitivity and specificity of ICD-10 codes were 5.4% and 99.9%, respectively, for identifying durotomies. CONCLUSIONS: The durotomy rate for lumbar decompressions was 14.5%. No differences in outcomes were detected except for increased LOS. Database studies relying on ICD codes should be interpreted with caution due to the limited sensitivity in identifying incidental durotomies.

Are Clinical or Surgical Outcomes Different Based on Whether the Same Surgeon or Hospital System Performs the Spine Revision?

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine the effects of discontinuity in care by changing surgeons, health systems, or increased time to revision surgery on revision spine fusion surgical outcomes and patient-reported outcomes. SUMMARY OF BACKGROUND INFORMATION: Patients undergoing revision spine fusion experience worse outcomes than those undergoing primary lumbar surgery. Those requiring complex revisions are often transferred to tertiary or quaternary referral centers under the assumption that those institutions may be more accustomed at performing those procedures. However, there remains a paucity of literature assessing the impact of discontinuity of care in revision spinal fusions. METHODS: Patients who underwent revision 1-3 level lumbar spine fusion 2011-2021 were grouped based on (1) revision performed by the index surgeon versus a different surgeon, (2) revision performed within the same versus different hospital system as the index procedure, and (3) length of time from index procedure. Multivariate regression for outcomes controlled for confounding differences. RESULTS: A total of 776 revision surgeries were included. An increased time interval between the index procedure and the revision surgery was predictive of a lower risk for subsequent revision procedure (odds ratio: 0.57, P =0.022). Revision surgeries performed by the same surgeon predicted a reduced length of hospital stay (ß: -0.14, P =0.001). Neither time to revision nor undergoing by the same surgeon or same practice predicted 90-day readmission rates. Patients are less likely to report meaningful improvement in Mental Component Score-12 or Physical Component Score-12 if revision surgery was performed at a different hospital system. CONCLUSIONS: Patients who have revision lumbar fusions have similar clinical outcomes regardless of whether their surgeon performed the index procedure. However, continuity of care with the same surgeon may reduce hospital length of stay and associated health care costs. The length of time between primary and revision surgery does not significantly impact patient-reported outcomes. LEVEL OF EVIDENCE: Level III.

Readmission and Resource Utilization in Patients From Socioeconomically Distressed Communities Following Lumbar Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine whether: (1) patients from communities of socioeconomic distress have higher readmission rates or postoperative healthcare resource utilization and (2) there are differences in patient-reported outcome measures (PROMs) based on socioeconomic distress. SUMMARY OF BACKGROUND DATA: Socioeconomic disparities affect health outcomes, but little evidence exists demonstrating the impact of socioeconomic distress on postoperative resource utilization or PROMs. METHODS: A retrospective review was performed on patients who underwent lumbar fusion at a single tertiary academic center from January 1, 2011 to June 30, 2021. Patients were classified according to the distressed communities index. Hospital readmission, postoperative prescriptions, patient telephone calls, follow-up office visits, and PROMs were recorded. Multivariate analysis with logistic, negative binomial regression or Poisson regression were used to investigate the effects of distressed communities index on postoperative resource utilization. Alpha was set at P <0.05. RESULTS: A total of 4472 patients were included for analysis. Readmission risk was higher in distressed communities (odds ratio, 1.75; 95% confidence interval, 1.06-2.87; P =0.028). Patients from distressed communities (odds ratio, 3.94; 95% confidence interval, 1.60-9.72; P =0.003) were also more likely to be readmitted for medical, but not surgical causes ( P =0.514), and distressed patients had worse preoperative (visual analog-scale Back, P <0.001) and postoperative (Oswestry disability index, P =0.048; visual analog-scale Leg, P =0.013) PROMs, while maintaining similar magnitudes of clinical improvement. Patients from distressed communities were more likely to be discharged to a nursing facility and inpatient rehabilitation unit (25.5%, P =0.032). The race was not independently associated with readmissions ( P =0.228). CONCLUSION: Socioeconomic distress is associated with increased postoperative health resource utilization. Patients from distressed communities have worse preoperative PROMs, but the overall magnitude of improvement is similar across all classes. LEVEL OF EVIDENCE: Level IV.

Predictors of Blood Transfusion in Patients Undergoing Lumbar Spinal Fusion.

OBJECTIVE: To determine risk factors for perioperative blood transfusion after lumbar fusion surgery. METHODS: After institutional review board approval, a retrospective cohort study of adult patients who underwent lumbar fusion at a single, urban tertiary academic center was retrospectively retrieved. Our primary outcome, blood transfusion, was collected via chart query. A receiver operating characteristic curve was used to evaluate the regression model. A P-value < 0.05 was considered statistically significant. RESULTS: Of the 3,842 patients, 282 (7.3%) required a blood transfusion. For patients undergoing posterolateral decompression and fusion, predictors of transfusion included age (P < 0.001) and more levels fused (P < 0.001). A higher preoperative hemoglobin level (P < 0.001) and revision surgery (P = 0.005) were protective of blood transfusion. For patients undergoing transforaminal lumbar interbody fusion, greater Elixhauser comorbidity index (P < 0.001), longer operative time (P = 0.040), and more levels fused (P = 0.030) were independent predictors of the need for blood transfusion. Patients with a higher body mass index (P = 0.012) and preoperative hemoglobin level (P < 0.001) had a reduced likelihood of receiving a transfusion. For circumferential fusion, greater age (P = 0.006) and longer operative times (P = 0.015) were independent predictors of blood transfusion, while a higher preoperative hemoglobin level (P < 0.001) and male sex (P = 0.002) were protective. CONCLUSIONS: Our analysis identified older age, lower body mass index, greater Elixhauser comorbidity index, longer operative duration, more levels fused, and lower preoperative hemoglobin levels as independent predictors of requiring a blood transfusion following lumbar spinal fusion. Different surgical approaches were not found to be associated with transfusion.

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.

Do On-Table Radiographs Predict Postoperative Sagittal Alignment after Posterior Lumbar Fusion?

OBJECTIVE: To determine if intraoperative on-table lumbar lordosis and segmental lordosis correlate with postoperative lordosis following single-level posterolateral decompression and fusion (PLDF) or transforaminal lumbar interbody fusion (TLIF). METHODS: Electronic medical records were reviewed for patients ≥18 years old who underwent PLDF or TLIF between 2012 and 2020. Lumbar lordosis and segmental lordosis were compared between pre-, intra-, and postoperative radiographs using paired t tests. Significance was set at P < 0.05. RESULTS: A total of 200 patients met inclusion criteria. No significant differences in preoperative, intraoperative, or postoperative measurements were found between groups. Patients who underwent PLDF experienced less disc height loss over 1 year postoperatively (PLDF: 0.45 ± 0.9 mm vs. TLIF: 1.2 ± 1.4 mm, P < 0.001). Lumbar lordosis significantly decreased between intraoperative to postoperative radiographs at 2-6 weeks for PLDF (Δ: -4.0°, P < 0.001) and TLIF (Δ: -5.6°, P < 0.001), but no change was identified between the intraoperative and >6 month postoperative radiographs for PLDF (Δ: -0.3°, P = 0.634) or TLIF (Δ: -1.6°, P = 0.087). Segmental lordosis significantly increased from the preoperative to post-instrumentation intraoperative radiographs for PLDF (Δ: 2.7°, P < 0.001) and TLIF (Δ: 1.8°, P < 0.001), but it subsequently decreased at the final follow up for PLDF (Δ: -1.9°, P < 0.001) and TLIF (Δ: -2.3°, P < 0.001). CONCLUSIONS: Subtle decreases in lumbar lordosis may be noticed in early postoperative radiographs compared with intraoperative images on Jackson operative tables. However, these changes are not present at 1-year follow-up as lumbar lordosis increases to a similar level as intraoperative fixation.

Comparing Posterior Lumbar Decompression and Fusion and Transforaminal Lumbar Interbody Fusion in Lumbar Degenerative Spondylolisthesis as Assessed by the CARDS Classification System.

OBJECTIVE: In a retrospective cohort study, we compared the outcomes among clinical and radiographic degenerative spondylolisthesis (CARDS) subtypes for patients undergoing posterior lumbar decompression and fusion (PLDF) or transforaminal lumbar interbody fusion (TLIF) and evaluated the CARDS system as a tool to guide clinical decisions regarding the treatment of degenerative spondylolisthesis (DS). METHODS: Patients undergoing PLDF or TLIF for DS from 2010 to 2020 were identified. The patients were grouped by the preoperative CARDS classification. Multivariate analysis was used to determine the effects of the treatment approach on the 1-year patient-reported outcome measures (PROMs) and 90-day surgical outcomes. RESULTS: A total of 1056 patients were included: 148 patients with type A DS, 323 with type B, 525 with type C, and 60 with type D. Patients with CARDS types A and C who underwent PLDF experienced a longer length of stay and were less likely to be discharged home. No differences were found in the incidence of revisions, complications, or readmissions between the surgical approaches. Patients with CARDS type A undergoing PLDF were less likely to achieve a minimal clinically important difference for back pain (36.8% vs. 76.7%; P = 0.013). No other significant differences were found in the PROMs among the CARDS subtypes. TLIF independently predicted for better leg pain improvement using the visual analog scale at 1 year of follow-up (ß = -2.92; P = 0.017) for patients with CARDS type A. Multivariable analysis demonstrated no significant differences in PROMs by surgical approach among the other CARDS subtypes. CONCLUSIONS: Patients with disc space collapse and endplate apposition (CARDS type A) appear to benefit from TLIF. However, patients with lumbar spondylolisthesis without disc space collapse or kyphotic angulation (CARDS types B and C) showed no benefit from additional interbody placement.

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.