Implementation of a Private Payer Bundled Payment Model While Maintaining High-Value Lumbar Spinal Fusion.

STUDY DESIGN: Retrospective single-institution cohort. OBJECTIVE: To evaluate the implementation of a commercial bundled payment model in patients undergoing lumbar spinal fusion. SUMMARY OF BACKGROUND DATA: BPCI-A caused significant losses for many physician practices, prompting private payers to establish their own bundled payment models. The feasibility of these private bundles has yet to be evaluated in spine fusion. METHODS: Patients undergoing lumbar fusion from October to December 2018 in BPCI-A before our institution's departure were included for BPCI-A analysis. Private bundle data was collected from 2018 to 2020. Analysis of the transition was conducted among Medicare-aged beneficiaries. Private bundles were grouped by calendar year (Y1, Y2, Y3). Stepwise multivariate linear regression was performed to measure independent predictors of net deficit. RESULTS: The net surplus was the lowest in Y1 ($2,395, P =0.03) but did not differ between our final year in BPCI-A and subsequent years in private bundles (all, P >0.05). AIR and SNF patient discharges decreased significantly in all private bundle years compared with BPCI. Readmissions fell from 10.7% (N=37) in BPCI-A to 4.4% (N=6) in Y2 and 4.5% (N=3) Y3 of private bundles ( P <0.001). Being in Y2 or Y3 was independently associated with a net surplus in comparison to the Y1 (ß: $11,728, P =0.001; ß: $11,643, P =0.002). Postoperatively, length of stay in days (ß: $-2,982, P <0.001), any readmission (ß: -$18,825, P =0.001), and discharge to AIR (ß: $-61,256, P <0.001) or SNF (ß: $-10,497, P =0.058) were all associated with a net deficit. CONCLUSIONS: Nongovernmental bundled payment models can be successfully implemented in lumbar spinal fusion patients. Constant price adjustment is necessary so bundled payments remain financially beneficial to both parties and systems overcome early losses. Private insurers who have more competition than the government may be more willing to provide mutually beneficial situations where cost is reduced for payers and health systems. LEVEL OF EVIDENCE: 3.

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.

Comparison of Postoperative Opioid Use After Anterior Cervical Diskectomy and Fusion or Posterior Cervical Fusion.

INTRODUCTION: Posterior cervical fusion (PCF) and anterior cervical diskectomy and fusion (ACDF) are two main surgical management options for the treatment of cervical spondylotic myelopathy. Although ACDF is less invasive than PCF which should theoretically reduce postoperative pain, it is still unknown whether this leads to reduced opioid use. Our objective was to evaluate whether PCF increases postoperative opioid use compared with ACDF. METHODS: We retrospectively identified all patients undergoing 2-level to 4-level ACDF or PCF at a single center from 2017 to 2021. Our state's prescription drug-monitoring program was queried for filled opioid prescriptions using milligrams morphine equivalents (MMEs) up to 1 year postoperatively. In-hospital opioid use was collected from the electronic medical record. Bivariate statistics compared ACDF and PCF cohorts. Multivariate linear regression was done to assess independent predictors of in-hospital opioid use and short-term (0 to 30 days), subacute (30 to 90 days), and long-term (3 to 12 months) opioid prescriptions. RESULTS: We included 211 ACDF patients and 91 PCF patients. Patients undergoing PCF used more opioids during admission (126.7 vs. 51.0 MME, P < 0.001) and refilled more MMEs in the short-term (118.2 vs. 86.1, P = 0.001) but not subacute (33.6 vs. 19.7, P = 0.174) or long-term (85.6 vs. 47.8, P = 0.310) period. A similar percent of patients in both groups refilled at least one prescription after 90 days (39.6% vs. 33.2%, P = 0.287). PCF (ß = 56.7, P = 0.001) and 30-day preoperative MMEs (ß = 0.28, P = 0.041) were associated with greater in-hospital opioid requirements. PCF (ß = 26.7, P = 0.039), C5 nerve root irritation (ß = 51.4, P = 0.019), and a history of depression (ß = 40.9, P < 0.001) were independently associated with 30-day postoperative MMEs. CONCLUSIONS: PCF is initially more painful than ACDF but does not lead to persistent opioid use. Surgeons should optimize multimodal analgesia protocols to reduce long-term narcotic usage rather than change the surgical approach.Level of Evidence:III.

Spine Surgical Subspecialty and Its Effect on Patient Outcomes: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: To perform a systematic review and meta-analysis to identify if intraoperative or postoperative differences in outcomes exist between orthopedic and neurological spine surgeons. SUMMARY OF BACKGROUND DATA: Spine surgeons may become board certified through orthopedic surgery or neurosurgical residency training, and recent literature has compared surgical outcomes between surgeons based on residency training background with conflicting results. MATERIALS AND METHODS: Using Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a search of PubMed and Scopus databases was conducted and included articles comparing outcomes between orthopedic spine surgeons and neurosurgeons. The Newcastle-Ottawa scale was used to determine the quality of studies. Forest plots were generated using mean differences (MD) for continuous variables and odds ratios (OR) for binomial variables, and 95% CI was reported. RESULTS: Of 615 search term results, 16 studies were identified for inclusion. Evaluation of the studies found no differences in readmission rates [OR, ref: orthopedics: 0.99 (95% CI: 0.901, 1.09); I2 = 80%], overall complication rates [OR, ref: orthopedics: 1.03 (95% CI: 0.97, 1.10); I2 = 70%], reoperation rates [OR, ref: orthopedics: 0.91 (95% CI: 0.82, 1.00); I2 = 86%], or overall length of hospital stay between orthopedic spine surgeons and neurosurgeons [MD: -0.19 days (95% CI: -0.38, 0.00); I2 = 98%]. However, neurosurgeons ordered a significantly lower rate of postoperative blood transfusions [OR, ref: orthopedics: 0.49 (95% CI: 0.41, 0.57); I2 = 75%] while orthopedic spine surgeons had shorter operative times [MD: 14.28 minutes, (95% CI: 8.07, 20.49), I2 = 97%]. CONCLUSIONS: Although there is significant data heterogeneity, our meta-analysis found that neurosurgeons and orthopedic spine surgeons have similar readmission, complication, and reoperation rates regardless of the type of spine surgery performed.

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

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

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.

Patients From Socioeconomically Distressed Communities Experience Similar Clinical Improvements Following Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: Retrospective cohort. OBJECTIVES: The aim was to compare patient-reported outcome measures (PROMs) following anterior cervical discectomy and fusion (ACDF) when categorizing patients based on socioeconomic status. Secondarily, we sought to compare PROMs based on race. SUMMARY OF BACKGROUND DATA: Social determinants of health are believed to affect outcomes following spine surgery, but there is limited literature on how combined socioeconomic status metrics affect PROMs following ACDF. MATERIALS AND METHODS: The authors identified patients who underwent primary elective one-level to four-level ACDF from 2014 to 2020. Patients were grouped based on their distressed community index (DCI) quintile (Distressed, At-Risk, Mid-tier, Comfortable, and Prosperous) and then race (White or Black). Multivariate regression for ∆PROMs was performed based on DCI group and race while controlling for baseline demographics and surgical characteristics. RESULTS: Of 1204 patients included in the study, all DCI groups improved across all PROMs, except mental health component score (MCS-12) for the Mid-tier group ( P =0.091). Patients in the Distressed/At-Risk group had worse baseline MCS-12, visual analog scale (VAS) Neck, and neck disability index (NDI). There were no differences in magnitude of improvement between DCI groups. Black patients had significantly worse baseline VAS Neck ( P =0.002) and Arm ( P =0.012) as well as worse postoperative MCS-12 ( P =0.016), PCS-12 ( P =0.03), VAS Neck ( P <0.001), VAS Arm ( P =0.004), and NDI ( P <0.001). Multivariable regression analysis did not identify any of the DCI groupings to be significant independent predictors of ∆PROMs, but being White was an independent predictor of greater improvement in ∆PCS-12 (ß=3.09, P =0.036) and ∆NDI (ß=-7.32, P =0.003). CONCLUSIONS: All patients experienced clinical improvements regardless of DCI or race despite patients in Distressed communities and Black patients having worse preoperative PROMs. Being from a distressed community was not an independent predictor of worse improvement in any PROMs, but Black patients had worse improvement in NDI compared with White patients. LEVEL OF EVIDENCE: 3.

Clinical Outcomes at One-year Follow-up for Patients With Surgical Site Infection After Spinal Fusion.

STUDY DESIGN: Retrospective case-control study. OBJECTIVE: To compare health-related quality of life outcomes at one-year follow-up between patients who did and did not develop surgical site infection (SSI) after thoracolumbar spinal fusion. SUMMARY OF BACKGROUND DATA: SSI is among the most common healthcare-associated complications. As healthcare systems increasingly emphasize the value of delivered care, there is an increased need to understand the clinical impact of SSIs. MATERIALS AND METHODS: A retrospective 3:1 (control:SSI) propensity-matched case-control study was conducted for adult patients who underwent thoracolumbar fusion from March 2014 to January 2020 at a single academic institution. Exclusion criteria included less than 18 years of age, incomplete preoperative and one-year postoperative patient-reported outcome measures, and revision surgery. Continuous and categorical data were compared via independent t tests and χ 2 tests, respectively. Intragroup analysis was performed using paired t tests. Regression analysis for ∆ patient-reported outcome measures (postoperative minus preoperative scores) controlled for demographics. The α was set at 0.05. RESULTS: A total of 140 patients (105 control, 35 SSI) were included in final analysis. The infections group had a higher rate of readmission (100% vs. 0.95%, P <0.001) and revision surgery (28.6% vs. 12.4%, P =0.048). Both groups improved significantly in Physical Component Score (control: P =0.013, SSI: P =0.039), Oswestry Disability Index (control: P <0.001, SSI: P =0.001), Visual Analog Scale (VAS) Back (both, P <0.001), and VAS Leg (control: P <0.001, SSI: P =0.030). Only the control group improved in Mental Component Score ( P <0.001 vs. SSI: P =0.228), but history of a SSI did not affect one-year improvement in ∆MCS-12 ( P =0.455) on regression analysis. VAS Leg improved significantly less in the infection group (-1.87 vs. -3.59, P =0.039), which was not significant after regression analysis (ß=1.75, P =0.050). CONCLUSION: Development of SSI after thoracolumbar fusion resulted in increased revision rates but did not influence patient improvement in one-year pain, functional disability, or physical and mental health status.

Marijuana Use and its Effect on Clinical Outcomes and Revision Rates in Patients Undergoing Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: To determine if (1) preoperative marijuana use increased complications, readmission, or reoperation rates following anterior cervical discectomy and fusion (ACDF), (2) identify if preoperative marijuana use resulted in worse patient-reported outcome measures (PROMs), and (3) investigate if preoperative marijuana use affects the quantity of opioid prescriptions in the perioperative period. SUMMARY OF BACKGROUND DATA: A growing number of states have legalized recreational and/or medical marijuana, thus increasing the number of patients who report preoperative marijuana use. The effects of marijuana on clinical outcomes and PROMs in the postoperative period are unknown. METHODS: All patients 18 years of age and older who underwent primary one- to four-level ACDF with preoperative marijuana use at our academic institution were retrospectively identified. A 3:1 propensity match was conducted to compare patients who used marijuana versus those who did not. Patient demographics, surgical characteristics, clinical outcomes, and PROMs were compared between groups. Multivariate regression models measured the effect of marijuana use on the likelihood of requiring a reoperation and whether marijuana use predicted inferior PROM improvements at the one-year postoperative period. RESULTS: Of the 240 patients included, 60 (25.0%) used marijuana preoperatively. Multivariate logistic regression analysis identified marijuana use (odds ratio=5.62, P <0.001) as a predictor of a cervical spine reoperation after ACDF. Patients who used marijuana preoperatively had worse one-year postoperative Physical Component Scores of the Short-Form 12 (PCS-12) ( P =0.001), Neck Disability Index ( P =0.003), Visual Analogue Scale (VAS) Arm ( P =0.044) and VAS Neck ( P =0.012). Multivariate linear regression found preoperative marijuana use did not independently predict improvement in PCS-12 (ß=-4.62, P =0.096), Neck Disability Index (ß=9.51, P =0.062), Mental Component Scores of the Short-Form 12 (MCS-12) (ß=-1.16, P =0.694), VAS Arm (ß=0.06, P =0.944), or VAS Neck (ß=-0.44, P =0.617). CONCLUSION: Preoperative marijuana use increased the risk of a cervical spine reoperation after ACDF, but it did not significantly change the amount of postoperative opioids used or the magnitude of improvement in PROMs. LEVEL OF EVIDENCE: Levwl III.

Depression Increases Posterior Cervical Decompression and Fusion Revision Rates and Diminishes Neck Disability Index Improvement.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: To determine if depression and/or anxiety significantly affect patient-reported outcome measures (PROMs) after posterior cervical decompression and fusion (PCDF). SUMMARY OF BACKGROUND DATA: Mental health diagnoses are receiving increased recognition for their influence of outcomes after spine surgery. The magnitude that mental health disorders contribute to patient-reported outcomes following PCDF requires increased awareness and understanding. MATERIALS AND METHODS: A review of electronic medical records identified patients who underwent a PCDF at a single institution during the years 2013-2020. Patients were placed into either depression/anxiety or nondepression/anxiety group based on their medical history. A delta score (∆) was calculated for all PROMs by subtracting postoperative from preoperative scores. χ 2 tests and t tests were utilized to analyze categorical and continuous data, respectively. Regression analysis determined independent predictors of change in PROMs. Alpha was set at 0.05. RESULTS: A total of 195 patients met inclusion criteria, with 60 (30.8%) having a prior diagnosis of depression/anxiety. The depression/anxiety group was younger (58.8 vs . 63.0, P =0.012), predominantly female (53.3% vs . 31.9%, P =0.007), and more frequently required revision surgery (11.7% vs . 0.74%, P =0.001). In addition, they had worse baseline mental component (MCS-12) (42.2 vs . 48.6, P <0.001), postoperative MCS-12 (46.5 vs . 52.9, P =0.002), postoperative neck disability index (NDI) (40.7 vs . 28.5, P =0.001), ∆NDI (-1.80 vs . -8.93, P =0.010), NDI minimum clinically important difference improvement (15.0% vs . 29.6%, P =0.046), and postoperative Visual Analog Scale (VAS) Neck scores (3.63 vs . 2.48, P =0.018). Only the nondepression/anxiety group improved in MCS-12 ( P =0.002) and NDI ( P <0.001) postoperatively. Depression and/or anxiety was an independent predictor of decreased magnitude of NDI improvement on regression analysis (ß=7.14, P =0.038). CONCLUSION: Patients with history of depression or anxiety demonstrate less improvement in patient-reported outcomes and a higher revision rate after posterior cervical fusion, highlighting the importance of mental health on clinical outcomes after spine surgery.

Does Age Younger Than 65 Affect Clinical Outcomes in Medicare Patients Undergoing Lumbar Fusion?

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: To determine if age (younger than 65) and Medicare status affect patient outcomes following lumbar fusion. SUMMARY OF BACKGROUND DATA: Medicare is a common spine surgery insurance provider, but most qualifying patients are older than age 65. There is a paucity of literature investigating clinical outcomes for Medicare patients under the age of 65. MATERIALS AND METHODS: Patients 40 years and older who underwent lumbar fusion surgery between 2014 and 2019 were queried from electronic medical records. Patients with >2 levels fused, >3 levels decompressed, incomplete patient-reported outcome measures (PROMs), revision procedures, and tumor/infection diagnosis were excluded. Patients were placed into 4 groups based on Medicare status and age: no Medicare under 65 years (NM<65), no Medicare 65 years or older (NM≥65), yes Medicare under 65 (YM<65), and yes Medicare 65 years or older (YM≥65). T tests and χ 2 tests analyzed univariate comparisons depending on continuous or categorical type. Multivariate regression for ∆PROMs controlled for confounders. Alpha was set at 0.05. RESULTS: Of the 1097 patients, 567 were NM<65 (51.7%), 133 were NM≥65 (12.1%), 42 were YM<65 (3.8%), and 355 were YM≥65 (32.4%). The YM<65 group had significantly worse preoperative Visual Analog Scale back ( P =0.01) and preoperative and postoperative Oswestry Disability Index (ODI), Short-Form 12 Mental Component Score (MCS-12), and Physical Component Score (PCS-12). However, on regression analysis, there were no significant differences in ∆PROMs for YM <65 compared with YM≥65, and NM<65. NM<65 (compared with YM<65) was an independent predictor of decreased improvement in ∆ODI following surgery (ß=12.61, P =0.007); however, overall the ODI was still lower in the NM<65 compared with the YM<65. CONCLUSION: Medicare patients younger than 65 years undergoing lumbar fusion had significantly worse preoperative and postoperative PROMs. The perioperative improvement in outcomes was similar between groups with the exception of ∆ODI, which demonstrated greater improvement in Medicare patients younger than 65 compared with non-Medicare patients younger than 65. LEVEL OF EVIDENCE: Level III (treatment).

Instrumentation Across the Cervicothoracic Junction Does Not Improve Patient-reported Outcomes in Multilevel Posterior Cervical Decompression and Fusion.

STUDY DESIGN: This was a retrospective cohort. OBJECTIVE: The objective of this study was to determine if instrumentation across the cervicothoracic junction (CTJ) in elective multilevel posterior cervical decompression and fusion (PCF) is associated with improved patient-reported outcome measures (PROMs). SUMMARY OF BACKGROUND DATA: Fusion across the CTJ may result in lower revision rates at the expense of prolonged operative duration. However, it is unclear whether constructs crossing the CTJ affect PROMs. MATERIALS AND METHODS: Standard Query Language (SQL) identified patients with PROMs who underwent elective multilevel PCF (≥3 levels) at our institution. Patients were grouped based on anatomic construct: crossing the CTJ (crossed) versus not crossing the CTJ (noncrossed). Subgroup analysis compared constructs stopping at C7 or T1. Independent t tests and χ 2 tests were utilized for continuous and categorical data, respectively. Regression analysis controlled for baseline demographics. The α was set at 0.05. RESULTS: Of the 160 patients included, the crossed group (92, 57.5%) had significantly more levels fused (5.27 vs. 3.71, P <0.001), longer operative duration (196 vs. 161 min, P =0.003), greater estimated blood loss (242 vs. 160 mL, P =0.021), and a decreased revision rate (1.09% vs. 10.3%, P =0.011). Neither crossing the CTJ (vs. noncrossed) nor constructs spanning C3-T1 (vs. C3-C7) were independent predictors of ∆PROMs (change in preoperative minus postoperative patient-reported outcomes) on regression analysis. However, C3-C7 constructs had a greater revision rate than C3-T1 constructs (15.6% vs. 1.96%, P =0.030). CONCLUSION: Crossing the CTJ in patients undergoing elective multilevel PCF was not an independent predictor of improvement in PROMs at 1 year, but they experienced lower revision rates. LEVEL OF EVIDENCE: Level III.

The Impact of Upper Cervical Spine Alignment on Patient-reported Outcome Measures in Anterior Cervical Decompression and Fusion.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: To determine the extent to which the upper cervical spine compensates for malalignment in the subaxial cervical spine, and how changes in upper cervical spine sagittal alignment affect patient-reported outcomes. SUMMARY OF BACKGROUND DATA: Previous research has investigated the relationship between clinical outcomes and radiographic parameters in the subaxial cervical spine following anterior cervical discectomy and fusion (ACDF). However, limited research exists regarding the upper cervical spine (occiput to C2), which accounts for up to 40% of neck movement and has been hypothesized to compensate for subaxial dysfunction. MATERIALS AND METHODS: Patients undergoing ACDF for cervical radiculopathy and/or myelopathy at a single center with minimum 1-year follow-up were included. Radiographic parameters including cervical sagittal vertical axis, C0 angle, C1 inclination angle, C2 slope, Occiput-C1 angle (Oc-C1 degrees), Oc-C2 degrees, Oc-C7 degrees, C1-C2 degrees, C1-C7 degrees, and C2-C7 degrees cervical lordosis (CL) were recorded preoperatively and postoperatively. Delta (Δ) values were calculated by subtracting preoperative values from postoperative values. Correlation analysis as well as multiple linear regression analysis was used to determine relationships between radiographic and clinical outcomes. Alpha was set at 0.05. RESULTS: A total of 264 patients were included (mean follow-up 20 mo). C2 slope significantly decreased for patients after surgery (Δ=-0.8, P =0.02), as did parameters of regional cervical lordosis (Oc-C7 degrees, C1-C7 degrees, and C2-C7 degrees; P <0.001, <0.001, and 0.01, respectively). Weak to moderate associations were observed between postoperative CL and C1 inclination ( r =-0.24, P <0.001), Oc-C1 degrees ( r =0.59, P <0.001), and C1-C2 degrees ( r =-0.23, P <0.001). Increased preoperative C1-C2 degrees and Oc-C2 degrees inversely correlated with preoperative SF-12 Mental Composite Score (MCS-12) scores ( r =-0.16, P =0.01 and r =-0.13, P =0.04). Cervical sagittal vertical axis was found to have weak but significant associations with Short Form-12 (SF-12) Physical Composite Score (PCS-12) ( r =-0.13, P =0.03) and MCS-12 ( r =0.12, P =0.05). CONCLUSION: No clinically significant relationship between upper cervical and subaxial cervical alignment was detected for patients undergoing ACDF for neurological symptoms. Upper cervical spine alignment was not found to be a significant predictor of patient-reported outcomes after ACDF. LEVEL OF EVIDENCE: Level III.

The Frequency, Reasoning, and Impact of Repeated Radiographs at the Initial Orthopedic Arthroplasty Visit.

BACKGROUND: Patients presenting to an orthopedic clinic with joint pain often seek prior care and imaging before consultation. It is unknown how often orthopedic surgeons must repeat imaging and whether repeat imaging has an impact on diagnosis or management. The purpose of this study was to determine the frequency, reason, and impact of repeating radiographs in outpatient orthopedic clinics. METHODS: Patients ≥18 years of age presenting with hip and/or knee pain were prospectively enrolled at five arthroplasty clinics from January 2019 until June 2020. Before the initial visit, surveys were distributed to patients regarding the reason for their visit, prior care, and prior diagnostic imaging. At the conclusion of the visit, surgeons reported if repeat radiographs were obtained, and if so, surgeons documented the views ordered, the reasoning for new films, and if diagnosis or management changed as a result. Patients were grouped based on repeat imaging status, and of those with repeat imaging, subgroup analysis compared patients based on if management changed. RESULTS: Of 292 patients, 256 (88%) had radiographs before their office visit, and 167 (65%) obtained repeat radiographs. Radiographs were most commonly repeated if they were inaccessible (47%), followed by if they were non-weight-bearing (40%). Repeated radiographs changed the diagnosis in 40% of patients and changed management in 22% of patients. CONCLUSION: Most patients underwent repeat radiography at their orthopedic visit. The primary reasons were owing to accessibility or the patient being non-weight-bearing. Repeat radiographs changed management in almost one-quarter of patients.