Predictors for Failure to Respond to Erector Spinae Plane Block Following Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To identify the risk factors associated with failure to respond to erector spinae plane (ESP) block following minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). SUMMARY OF BACKGROUND DATA: ESP block is an emerging opioid-sparing regional anesthetic that has been shown to reduce immediate postoperative pain and opioid demand following MI-TLIF-however, not all patients who receive ESP blocks perioperatively experience a reduction in immediate postoperative pain. METHODS: This was a retrospective review of consecutive patients undergoing 1-level MI-TLIF who received ESP blocks by a single anesthesiologist perioperatively at a single institution. ESP blocks were administered in the OR following induction. Failure to respond to ESP block was defined as patients with a first numerical rating scale (NRS) score post-surgery of >5.7 (mean immediate postoperative NRS score of control cohort undergoing MI TLIF without ESP block). Multivariable logistic regressions were performed to identify predictors for failure to respond to ESP block. RESULTS: A total of 134 patients were included (mean age 60.6 years, 43.3% females). The median and interquartile range (IQR) first pain score post-surgery was 2.5 (0.0-7.5). Forty-nine (36.6%) of patients failed to respond to ESP block. In the multivariable regression analysis, several independent predictors for failure to respond to ESP block following MI TLIF were identified: female sex (OR 2.33, 95% CI 1.04-5.98, P=0.040), preoperative opioid use (OR 2.75, 95% CI 1.03- 7.30, P=0.043), anxiety requiring medication (OR 3.83, 95% CI 1.27-11.49, P=0.017), and hyperlipidemia (OR 3.15, 95% CI 1.31-7.55, P=0.010). CONCLUSIONS: Our study identified several predictors for failure to respond to ESP block following MI TLIF including female sex, preoperative opioid pain medication use, anxiety, and hyperlipidemia. These findings may help inform the approach to counseling patients on perioperative outcomes and pain expectations following MI-TLIF with ESP block. LEVEL OF EVIDENCE: III.

Telemedicine in Arthroplasty Patients: Which Factors Are Associated With High Satisfaction?

Background: During the initial coronavirus pandemic lockdown period, remote hip and knee arthroplasty care was heavily employed out of necessity. However, data on patient satisfaction with telemedicine specific to hip and knee arthroplasty patients remains unknown. Methods: All patients who had a telemedicine visit in the hip and knee arthroplasty department and completed a telemedicine satisfaction survey at a specialty hospital from April 1, 2020, to December 31, 2020, were identified. Patient satisfaction with telemedicine, gauged through a series of questions, were analyzed and evaluated over time. Independent factors associated with high satisfaction, defined as the "Top Box" response to the survey question "Likelihood of your recommending our video visit service to others," were identified. Results: Overall, 29,003 patients who had an in-person or telemedicine visit in the hip and knee arthroplasty department during the study period were identified. During the initial coronavirus pandemic lockdown period, defined as April 1, 2020-May 31, 2020, rate of overall telemedicine utilization was approximately 84%. After the initial lockdown period, the rate of overall telemedicine utilization was approximately 8% of all visits per month. Average satisfaction scores for a series of 14 questions were consistently above 4.5 out of 5. Multivariable regression revealed younger age, particularly 18-64 years old, to be the only independent factor associated with high satisfaction with telemedicine. The rate of high satisfaction remained statistically similar throughout the study period (P > .05). Conclusions: Patient satisfaction with telemedicine was consistently high in various domains and remained high throughout the study period, regardless of loosened pandemic restrictions. This technology will most likely continue to be utilized, but perhaps it should be targeted at patients younger than 65 years of age.

Telemedicine in Spine Patients: Utilization and Satisfaction Remain High Even After Easing of COVID-19 Lockdown Restrictions.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The objectives of the present study were to (1) define telemedicine utilization rates during and after the initial height of the COVID-19 lockdown period and (2) determine patient satisfaction with telemedicine during and after the initial height of the COVID-19 lockdown period for spine patients at an orthopedic specialty hospital. SUMMARY OF BACKGROUND DATA: Previous studies have shown high patient satisfaction with telemedicine during the initial height of the COVID-19 pandemic. However, there exists limited data about spine telemedicine utilization and patient satisfaction after the reopening of in-person office visits and the easing of restrictions on elective surgical care. MATERIALS AND METHODS: All patients who had an in-person or telemedicine visit at an urban tertiary specialty hospital from April 1, 2020 to April 15, 2021 were identified. Rates of overall telemedicine utilization over time were delineated. Patient satisfaction with telemedicine, as assessed through a series of questionnaires, was also evaluated over time. RESULTS: Overall, 60,368 patients were identified. Of these, 19,568 patients (32.4%) had telemedicine visit. During the peak initial coronavirus lockdown period, the rate of overall telemedicine utilization, on average, was greater than 90%. After the peak period, the rate of overall telemedicine utilization on average was at ~29% of all visits per month. The percentage of patients who would have been definitely comfortable if the telemedicine visit had been in-person increased over the entire study period ( P <0.001). Despite this, patient satisfaction based on survey responses remained statistically similar throughout the study period ( P >0.05). CONCLUSION: The rate of telemedicine utilization in spine patients remains high, at ~one-third of all visits, even after the initial peak coronavirus lockdown period. In addition, patient satisfaction with telemedicine remained consistent throughout the study period, regardless of pandemic restrictions on in-person visits. LEVEL OF EVIDENCE: 3.

Early-onset scoliosis.

PURPOSE OF REVIEW: The aim of this review is to provide the reader with the most updated available information so that it can be helpful in the approach of patients with early-onset scoliosis (EOS). RECENT FINDINGS: While confirming the efficacy and safety of classic techniques for the treatment of EOS such as traditional growing rods or Mehta casting, recent research suggests that there is room for improvement with less invasive techniques. SUMMARY: The most important goal when treating patients with EOS should be to promote rib cage expansion and lung development. Different techniques have been described and may be used depending on the specific patient's characteristics.

Unplanned readmissions following ambulatory spine surgery: assessing common reasons and risk factors.

BACKGROUND CONTEXT: Although outpatient spine surgery is becoming increasingly popular in the United States, unplanned readmission following outpatient surgery remains a significant postoperative concern. PURPOSE: This study aimed to (1) describe the incidence and timing of 30-day unplanned readmission after ambulatory lumbar and cervical spine surgery (2) evaluate the common reasons for readmission, and (3) identify factors associated with readmission in this population. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Patients who underwent ambulatory cervical or lumbar spine surgery between 2015 and 2020 were identified in the National Surgical Quality Improvement Program (NSQIP) database. OUTCOME MEASURES: Hospital readmission within 30 postoperative days. METHODS: Patients who underwent ambulatory cervical or lumbar spine surgery between 2015 and 2020 were identified using the National Surgical Quality Improvement Program (NSQIP) database. Reasons for and timing of unplanned readmissions were recorded. Multivariable poisson regressions were employed to determine any independent predictors of readmission. RESULTS: A total of 33,092 ambulatory cervical and 68,115 ambulatory lumbar spine surgery patients were identified. Incidences of 30-day readmission were 3.37% and 3.07% among cervical and lumbar patients, respectively. The most common surgical site-related reasons for readmission included uncontrolled pain, recurrence of disc herniation or major symptom, and postoperative hematoma/seroma. Common nonsurgical site-related reasons included gastrointestinal, neurological, and cardiovascular complications. Factors associated with readmission among cervical patients included age ≥55, BMI ≥35, functional dependence, diabetes, smoking, COPD, and steroid use, whereas factors associated with readmission following lumbar spine surgery included age ≥65, female sex, BMI ≥35, functional dependence, ASA ≥3, diabetes, smoking, COPD, and hypertension (p<.05 for all). CONCLUSION: This study highlights the common reasons and factors associated with unplanned readmission following ambulatory spine surgery. Consideration of these factors may be critical to ensuring appropriate patient selection for ambulatory spine surgery.

Male sex is an independent risk factor for patellar osteochondral fractures following acute patellar dislocation in pediatric patients.

PURPOSE: Although most patellar dislocations are associated with medial patellofemoral ligament (MPFL) injury, many patients also sustain concomitant patellar osteochondral fractures following a patellar dislocation. Few prior studies have described or evaluated risk factors for patellar osteochondral fractures in pediatric patients. The purpose of the present study was to describe the incidenceand location of patellar osteochondral fractures following acute patellar dislocation in pediatric patients. In addition, we described risk factors for patellar osteochondral fractures in this population. We hypothesized that most fractures would occur at the inferomedial quadrant of the patella following a traumatic injury mechanism. METHODS: Following Institutional Review Board approval, the electronic medical record was queried to identify pediatric patients ≤ 18 years old who underwent MPFL reconstruction (MPFLR) or non-operative treatment for patellar instability between July 2016 and February 2020. Osteochondral fractures were defined as full-thickness chondral injuries with attached subchondral bone or purely osseous injuries measuring ≥ 3 mm (mm) in at least two magnetic resonance imaging (MRI) planes. Patients were included in the study if they had complete preoperative x-ray and MRI studies with minimum 6-month follow-up. Patients were excluded if they had incomplete imaging, isolated chondral fractures, or less than 6 months follow-up. Univariate analysis was used to identify patient factors associated with osteochondral fractures. Multivariate regression analysis was used to identify risk factors for osteochondral fractures. RESULTS: Sixty patients (63 knees) were included in the study, 15 (23.8%) of whom had a patellar osteochondral fracture. The majority of osteochondral fractures (87%) involved the inferomedial quadrant of the patella. Univariate analysis showed an association between male sex (p = 0.041), skeletal immaturity (p = 0.028), and decreased patellar tilt (p = 0.021) and patellar osteochondral fractures. Multivariate regression analysis identified male sex as an independent risk factor for osteochondral fractures (relative risk: 4.8, 95% confidence interval [CI]: 1.08-20.9, p = 0.039). No patients had recurrent dislocation at minimum 6-month follow-up. All patients with osteochondral fractures returned to sports at most recent follow up. CONCLUSION: In this study, 23% of pediatric patients with acute patellar dislocations have a concomitant patellar osteochondral fracture. The majority of patellar osteochondral fractures involve the inferomedial quadrant of the patella. Male sex is an independent risk factor for patellar osteochondral fractures, and skeletal immaturity is associated with patellar osteochondral fractures in this population. LEVEL OF EVIDENCE: Level III.

Patient-Reported Allergies Do Not Affect Long-Term Patient-Reported Outcome Measures After Spine Surgery.

BACKGROUND: A gap in the literature exists regarding the association between number of allergies and patient-reported outcomes measures (PROMs) for patients undergoing spine surgery. METHODS: Consecutive cervical or lumbar spine surgery patients were identified from a prospective registry from April 2017 to July 2020. Patients were grouped into those with 0, 1, 2, or ≥3 allergies. Demographics were compared between the groups. PROMs included Neck Disability Index, Oswestry Disability Index, visual analog scale (VAS) neck pain, VAS arm pain, VAS back pain, VAS leg pain, short form 12 (SF-12) physical component score, SF-12 mental component score, and patient-reported outcomes measurement information system physical function (PROMIS-PF), and outcomes were compared between the groups through multivariable analysis at up to 1-year follow-up. Associations between number of allergies and achieving a minimal clinically important difference (MCID) in the 9 aforementioned PROMs at 1-year follow-up were assessed. RESULTS: This study included 148 cervical and 517 lumbar patients. After controlling for demographic differences, a higher number of allergies was associated with less improvement in VAS neck pain, SF-12 physical component score, and PROMIS-PF at 12 weeks following cervical surgery and less improvement in PROMIS-PF at 2 weeks following lumbar surgery (P < 0.05). However, these associations failed to persist after 6 months and 12 weeks following surgery in cervical and lumbar patients, respectively (P > 0.05). No association was identified between number of allergies and achievement of MCID in any of the 9 studied PROMs at 1-year follow-up. CONCLUSIONS: The higher number of allergies was associated with less improvement in PROMs in the early postoperative period but not at longer-term follow-up. CLINICAL RELEVANCE: These findings provide data that can be utilized while counseling patients and setting postoperative expectations.

Identification of Novel Genetic Markers for the Risk of Spinal Pathologies: A Genome-Wide Association Study of 2 Biobanks.

BACKGROUND: Identifying genetic risk factors for spinal disorders may lead to knowledge regarding underlying molecular mechanisms and the development of new treatments. METHODS: Cases of lumbar spondylolisthesis, spinal stenosis, degenerative disc disease, and pseudarthrosis after spinal fusion were identified from the UK Biobank. Controls were patients without the diagnosis. Whole-genome regressions were used to test for genetic variants potentially implicated in the occurrence of each phenotype. External validation was performed in FinnGen. RESULTS: A total of 389,413 participants were identified from the UK Biobank. A locus on chromosome 2 spanning GFPT1, NFU1, AAK1, and LOC124906020 was implicated in lumbar spondylolisthesis. Two loci on chromosomes 2 and 12 spanning genes GFPT1, NFU1, and PDE3A were implicated in spinal stenosis. Three loci on chromosomes 6, 10, and 15 spanning genes CHST3, LOC102723493, and SMAD3 were implicated in degenerative disc disease. Finally, 2 novel loci on chromosomes 5 and 9, with the latter corresponding to the LOC105376270 gene, were implicated in pseudarthrosis. Some of these variants associated with spinal stenosis and degenerative disc disease were also replicated in FinnGen. CONCLUSIONS: This study revealed nucleotide variations in select genetic loci that were potentially implicated in 4 different spinal pathologies, providing potential insights into the pathological mechanisms. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Trends in Outpatient Cervical Spine Surgery: Are There Emerging Disparities?

STUDY DESIGN: Retrospective analysis on prospectively collected data. OBJECTIVE: The purposes of this study were to (1) assess disparities in relative utilization of outpatient cervical spine surgery between White and Black patients from 2010 to 2019 and (2) to measure how these racial differences have evolved over time. SUMMARY OF BACKGROUND DATA: Although outpatient spine surgery has become increasingly popularized over the last decade, it remains unknown how racial disparities in surgical utilization have translated to the outpatient setting and whether restrictive patterns of access to outpatient cervical spine procedures may exist. METHODS: A retrospective cohort study from 2010 to 2019 was conducted using the National Surgical Quality Improvement Program database. Relative utilization of outpatient (same-day discharge) for anterior cervical discectomy and fusion (OP-ACDF) and cervical disk replacement (OP-CDR) were assessed and trended over time between races. Multivariable regressions were subsequently utilized to adjust for baseline patient factors and comorbidities. RESULTS: Overall, Black patients were significantly less likely to undergo OP-ACDF or OP-CDR surgery when compared with White patients ( P <0.03 for both OP-ACDF and OP-CDR). From 2010 to 2019, a persisting disparity over time was found in outpatient utilization for both ACDF and CDR ( e.g. White vs. Black OP-ACDF: 6.0% vs. 3.1% in 2010 compared with 16.7% vs. 8.5% in 2019). These results held in all adjusted analyses. CONCLUSIONS: To our knowledge, this is the first study reporting racial disparities in outpatient spine surgery and demonstrates an emerging disparity in outpatient cervical spine utilization among Black patients. These restrictive patterns of access to same-day outpatient hospital and surgery centers may contribute to broader disparities in the overall utilization of major spine procedures that have been previously reported. Renewed interventions are needed to both understand and address these emerging inequalities in outpatient care before they become more firmly established within our orthopedic and neurosurgery spine delivery systems.

Opioid prescription trends after ambulatory anterior cervical discectomy and fusion.

BACKGROUND CONTEXT: Opioid utilization has been well studied for inpatient anterior cervical discectomy and fusion (ACDF). However, the amount and type of opioids prescribed following ambulatory ACDF and the associated risk of persistent use are largely unknown. PURPOSE: To characterize opioid prescription filling following single-level ambulatory ACDF compared with inpatient procedures. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Opioid-naive patients who underwent ambulatory (no overnight stay) or inpatient single-level ACDF from 2011 to 2019 were identified from a national insurance database. OUTCOME MEASURES: Rate, amount, and type of perioperative opioid prescription. METHODS: Opioid-naive patients who underwent ambulatory (no overnight stay) or inpatient single-level ACDF from 2011 to 2019 were identified from a national insurance database. Perioperative opioids were defined as opioid prescriptions 30 days before and 14 days after the procedure. Rate, amount, and type of opioid prescription were characterized. Multivariable analyses controlling for any differences in demographics and comorbidities between the two treatment groups were utilized to determine any association between surgical setting and persistent opioid use (defined as the patient still filling new opioid prescriptions >90 days postoperatively). RESULTS: A total of 42,521 opioid-naive patients were identified, of which 2,850 were ambulatory and 39,671 were inpatient. Ambulatory ACDF was associated with slightly increased perioperative opioid prescription filling (52.7% vs 47.3% for inpatient procedures; p<.001). Among the 20,280 patients (47.7%) who filled perioperative opioid prescriptions, the average amount of opioids prescribed (in morphine milligram equivalents) was similar between ambulatory and inpatient procedures (550 vs 540, p=.413). There was no association between surgical setting and persistent opioid use in patients who filled a perioperative opioid prescription, even after controlling for comorbidities, (adjusted odds ratio, 1.15, p=.066). CONCLUSIONS: Ambulatory ACDF patients who filled perioperative opioid prescriptions were prescribed a similar amount of opioids as those undergoing inpatient procedures. Further, ambulatory ACDF does not appear to be a risk factor for persistent opioid use. These findings are important for patient counseling as well as support the safety profile of this new surgical pathway.

Increased Complications in Octogenarians Undergoing Same-Day Discharge following Total Knee Arthroplasty: A Matched Cohort Analysis.

Same-day discharge pathways in total knee arthroplasty (TKA) are gaining popularity as a means to increase patient satisfaction and reduce overall costs, but these pathways have not been thoroughly evaluated in potentially at-risk populations, such as in patients ≥80 years old. The purpose of this study was to compare 90-day complications and mortality following same-day discharge after primary TKA in patients ≥80 years old and those <80 years old. Patients who underwent unilateral primary TKA, were discharged on postoperative day 0, and had a minimum 90-day follow-up were identified in a national insurance claims database (PearlDiver Technologies) using Current Procedural Terminology code 27447. These patients were stratified into two cohorts based upon age: (1) nonoctogenarians (<80 years old) and (2) octogenarians (≥80 years old). These cohorts were propensity matched based upon sex, Charlson comorbidity index, and obesity status. Univariate analysis was performed to determine differences in 90-day complications and mortality between the two cohorts. In total, 1,111 patients were included in each cohort. Both cohorts were successfully matched, with no observed differences in matched parameters for demographics or comorbidities. There was no significant difference in 90-day mortality between the two cohorts (p = 0.896). However, octogenarians were at significantly increased risk of postoperative atrial fibrillation (20.8 vs. 10.4%; p < 0.001), nonatrial fibrillation arrhythmias (8.4 vs. 5.6%; p = 0.009), pneumonia (4.5 vs. 2.2%; p = 0.002), stroke (3.1 vs. 1.7%; p = 0.037), heart failure (10.5 vs. 7.5%; p = 0.012), and urinary tract infection (UTI; 14.3 vs. 9.4%; p < 0.001) compared with the nonoctogenarian cohort. Relative to matched controls, octogenarians were at significantly increased risk of numerous 90-day medical complications following same-day primary TKA, including cardiopulmonary complications, stroke, and UTI. Clinicians should be cognizant of these complications and counsel patients appropriately when electing to perform same-day TKA in the octogenarian population.

Computer-Assisted Navigation Is Associated With Decreased Rates of Hardware-Related Revision After Instrumented Posterior Lumbar Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To (1) define utilization trends for navigated instrumented posterior lumbar fusion (PLF), (2) compare reasons and rates of revision at 30-day, 60-day, 90-day, and 1-year follow-up, and (3) compare 90-day perioperative complications between navigated versus conventional instrumented PLF. METHODS: Patients who underwent navigated or conventional instrumented PLF were identified from the Humana insurance database using the PearlDiver Patient Records between 2007-2017. Usage of navigation was characterized. Patient demographics and operative characteristics (number of levels fused, interbody usage) were compared between the 2 treatment groups. Propensity score matching was done and comparisons were made for revision rates at different follow-up periods (categorized by reasons) and other 90-day perioperative complications. RESULTS: This study included 1,648 navigated and 23 429 conventional instrumented PLF. Navigated cases increased over the years studied to approximately 10% in 2017. Statistical analysis after propensity score matching revealed significantly lower rates of hardware-related revision at 90-day follow-up in the navigated cohort (0.49% versus 1.15%, P = .033). At 1-year follow-up, the navigated cohort continued to have significantly lower rates of hardware-related revision (1.70% versus 2.73%, P = .044) as well as all cause revision (2.67% versus 4.00%, P = .032). There were no statistical differences between the 2 cohorts in any of the 90-day perioperative complications studied, such as cellulitis and blood transfusion (P > .05 for all). CONCLUSIONS: These findings suggest that navigation is associated with reductions in hardware-related revisions after instrumented PLF. However, these results should be interpreted cautiously in the setting of potential confounding by other unmeasured variables.

Same-Day Discharge Total Knee Arthroplasty in Octogenarians.

BACKGROUND: One of the most important aspects of the transition to outpatient (OP) arthroplasty is patient selection, with guidance traditionally recommending that OP total knee arthroplasty (TKA) be reserved for patients <80 years old. However, there are limited data as to whether older age should really be considered a contraindication to OP-TKA. The purpose of this study is to assess the risk of complications and readmissions following OP-TKA in patients ≥80 years old. METHODS: This is a retrospective, propensity-matched cohort study of the National Surgical Quality Improvement Program database from 2011 to 2019. Patients ≥80 years undergoing OP (same-day discharge) TKA were propensity matched to patients ≥80 years undergoing inpatient (IP) TKA based on age, gender, race, body mass index, American Society of Anesthesiologists classification, functional status, smoking status, anesthetic type, and medical comorbidities. There were 1,418 patients (709 IPs and 709 OPs) included. All baseline factors were successfully matched between IP-TKA versus OP-TKA (P ≥ .18 for all). Thirty-day complications, readmissions, reoperations, and mortality were subsequently analyzed. RESULTS: Thirty-day readmission rates were identical between patients undergoing IP-TKA and OP-TKA (3.5% versus 3.5%, P = 1.0). Similarly, there was no significant difference in the incidence of major complications (2.7% versus 2.0%, P = .38), reoperations (1.3% versus 0.8%, P = .44), or mortalities (0.3% versus 0.3%, P = 1.0) within 30 days. CONCLUSION: Octogenarians undergoing OP-TKA had comparable complication rates to similar patients undergoing IP-TKA. OP-TKA can be performed safely in select octogenarians and age ≥80 years likely does not need to be a uniform contraindication to OP-TKA.

Contemporary Analysis of Inconsistencies Between Physician-reported Disclosures at the AAOS Annual Meeting and Industry-reported Financial Disclosures in the Open Payments Database.

INTRODUCTION: Healthcare regulators and patients are increasingly interested in financial transparency between physicians and the industry because of concerns of bias. METHODS: Disclosures for every first and last author with a medical degree from the United States associated with a poster or podium presentation at the American Academy of Orthopaedic Surgeons (AAOS) 2019 Annual Meeting were identified. Author characteristics were collected. AAOS disclosures were then compared with disclosures from the Open Payments Database to determine whether any inconsistencies existed. RESULTS: In total, 2,503 AAOS presenters were identified, and 1,380 authors met the inclusion criteria. Using AAOS disclosures as the standard comparator, 482 authors (35%) had an inconsistency in any category between AAOS disclosures and the Open Payments Database. Inconsistency rates for each category were 8% for royalties, 10% for speaker's fee, 15% for paid consultant, 16% for research, 14% for stocks, and 1% for other financial support. DISCUSSION: Although the inconsistency rate for each category has improved over the years, the overall inconsistency rate between physician-reported disclosures at a recent AAOS Annual Meeting and industry-reported relationships reported in the Open Payments Database was still 35%.

Telemedicine Visits Can Generate Highly Accurate Diagnoses and Surgical Plans for Spine Patients.

STUDY DESIGN: A Retrospective cohort study. OBJECTIVE: To (1) assess whether diagnoses and surgical plans established during a new patient telemedicine visit changed following an in-person evaluation and (2) determine any differences in perioperative outcomes between patients who only had a telemedicine visit before surgery versus those who had a telemedicine visit followed by an in-person evaluation before surgery. SUMMARY OF BACKGROUND DATA: Data on capability of telemedicine to deliver high-quality preoperative assessment without a traditional in-person interaction and physical examination is lacking. MATERIALS AND METHODS: Records of patients who had a new patient telemedicine visit and indicated for surgery with documented specific diagnosis as well as surgical plans from a spine department at an urban tertiary center from April 2020 to April 2021 were reviewed. For a subset of patients that had a follow-up in-person evaluation before surgery, these diagnoses and plans were compared. Perioperative outcomes were compared between patients who only had a telemedicine visit before surgery versus those who had a telemedicine visit followed by an in-person evaluation before surgery. RESULTS: A total of 166 patients were included. Of these, 101 patients (61%) only had a new patient telemedicine visit before surgery while 65 (39%) had a telemedicine visit followed by an in-person evaluation. There were no differences in the rate of case cancellations before surgery and patient-reported outcome measures between these two groups ( P >0.05). Of 65 patients who had both a telemedicine followed by an in-person visit, the diagnosis was unchanged for 61 patients (94%) and the surgical plan did not change for 52 patients (80%). The main reason for surgical plan change was due to updated findings on new imaging, 10 patients, (77%). CONCLUSIONS: The current study suggests that telemedicine evaluations can provide an effective means of preoperative assessment for spine patients. LEVEL OF EVIDENCE: Level 3.

Current treatment and decision-making factors leading to fusion vs decompression for one-level degenerative spondylolisthesis: survey results from members of the Lumbar Spine Research Society and Society of Minimally Invasive Spine Surgery.

BACKGROUND: Degenerative spondylolisthesis (DS) is one of the most common pathologies spine surgeons treat. While a number of potential factors have been identified, there is no current consensus on which variables most impact the decision to fuse vs. decompress alone in this population. PURPOSE: The purpose of this study was to describe current DS treatment practices and identify both the radiographic and clinical factors leading to the decision to fuse segments for one level DS. STUDY DESIGN/SETTING: Descriptive cross-sectional survey. PATIENT SAMPLE: Surveys were administered to members of Lumbar Spine Research Society and Society of Minimally Invasive Spine Surgery. OUTCOME MEASURES: Surgeon demographics and treatment practices were reported. Radiographic and clinical parameters were ranked by each surgeon with regards to their importance. METHODS: The primary analysis was limited to completed surveys. Baseline characteristics were summarized. Clinical and radiographic parameters were ranked and compared. Ranking of each clinical and radiographic parameters was reported using best and worst rank, mean rank position, and percentiles. The most important, top 3 most important, and top 5 most important parameters were ordered given each parameter's ranking frequency. RESULTS: 381 surveys were returned completed. With regards to fusion vs. decompression, 19.9% fuse all cases, 39.1% fuse > 75%, 17.8% fuse 50%-75%, and 23.2% fuse <25%. The most common decompressive technique was a partial laminotomy (51.4%), followed by full laminectomy (28.9%). 82.2% of respondents instrument all fusion cases. Instability (93.2%), spondylolisthesis grade (59.8%), and laterolisthesis (37.3%) were the most common radiographic factors impacting the decision to fuse. With regards to the clinical factors leading to fusion, mechanical low back pain (83.2%), activity level (58.3%), and neurogenic claudication (42.8%) were the top 3 clinical parameters. CONCLUSIONS: There is little consensus on the treatment of DS, with society members showing substantial variation in treatment patterns with the majority utilizing fusion for treatment. The most common radiographic parameters impacting treatment are instability, spondylolisthesis grade, and laterolisthesis while mechanical low back pain, activity level, and neurogenic claudication are the most common clinical parameters.

Minimally Invasive Lumbar Decompression Versus Minimally Invasive Transforaminal Lumbar Interbody Fusion for Treatment of Low-Grade Lumbar Degenerative Spondylolisthesis.

STUDY DESIGN: A retrospective cohort comparison study. OBJECTIVE: To compare perioperative outcomes, radiographic parameters, and patient-reported outcome measures (PROMs) between minimally invasive unilateral laminotomy with bilateral decompression (MIS-ULBD) versus MIS transforaminal lumbar interbody fusion (MIS-TLIF) for treatment of low-grade lumbar degenerative spondylolisthesis. SUMMARY OF BACKGROUND DATA: While lumbar degenerative spondylolisthesis is a common condition, optimal surgical treatment remains controversial. Newer MIS techniques, which preserve bone, paraspinal musculature, and posterior midline stabilizers, are thought to reduce the risk of iatrogenic instability and may obviate the need for fusion. However, few comparative studies of MIS techniques for low-grade lumbar degenerative spondylolisthesis currently exist. MATERIALS AND METHODS: Consecutive patients with low-grade (Meyerding grade I or II) lumbar degenerative spondylolisthesis treated with single-level MIS-ULBD or MIS-TLIF were identified retrospectively from a prospectively collected spine surgery registry from April 2017 to November 2021. Perioperative outcomes, radiographic data, and PROMs were assessed. RESULTS: A total of 188 patients underwent either MIS-ULBD or MIS-TLIF (79 MIS-ULBD and 109 MIS-TLIF). Patients who underwent MIS-ULBD tended to be older, had higher Charlson Comorbidity Index, lower mean percentage back pain, higher percentage of L4/L5 pathology, shorter operative time, lower estimated blood loss, and lower postoperative pain ( P <0.05). In both groups, there were statistically significant improvements at one year for five of the six PROMs studied: Oswestry Disability Index (ODI), visual analog scale (VAS)-back pain, VAS-leg pain, Short Form 12 Physical Component Score (SF12-PCS), and Patient-Reported Outcomes Measurement Information System (PROMIS) ( P <0.05). On multivariate analysis controlling for confounders, there were no associations between procedure type and achieving minimal clinically important difference at one year in any of the PROMs studied. CONCLUSIONS: The current study suggests that both MIS-ULBD and MIS-TLIF result in significant improvements in pain and physical function for patients with low-grade lumbar degenerative spondylolisthesis. LEVEL OF EVIDENCES: 3.

Association between muscle health and patient-reported outcomes after lumbar microdiscectomy: early results.

BACKGROUND CONTEXT: Poor muscle health has been implicated as a source of back pain among patients with lumbar spine pathology. Recently, a novel magnetic resonance imaging (MRI)-based lumbar muscle health grade was shown to correlate with health-related quality of life scores. However, the impact of muscle health on postoperative functional outcomes following spine surgery remains to be investigated. PURPOSE: To determine whether muscle health grade measured by preoperative psoas and paralumbar muscle cross-sectional areas impact the achievement of minimal clinically important difference (MCID) following lumbar microdiscectomy. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Consecutive patients who underwent 1-level lumbar microdiscectomy in a single institution between 2017 and 2021. OUTCOME MEASURES: Rate of MCID achievement, time to MCID achievement, PROMs including Oswestry Disability Index (ODI), visual analog scale for back pain (VAS back), VAS leg, Short Form 12 Physical Component Summary (SF-12 PCS), SF-12 Mental Component Summary (SF-12 MCS), and Patient Reported Outcomes Measurement Information System Physical Function (PROMIS PF). METHODS: Two previously validated methods for muscle health grading were applied. Axial T2 MRI were analyzed for muscle measurements. The psoas-based method utilized the normalized total psoas area (NTPA), which is the psoas cross-sectional area divided by the square of patient height (mm2/m2). Patients were divided into low and high NTPA groups based on sex-specific lowest quartile NTPA thresholds. The paralumbar-based method incorporated the paralumbar cross-sectional area normalized by body mass index (PL-CSA/BMI) and Goutallier classification. Score of 1 was added for either PL-CSA/BMI >130 or Goutallier class of ≤2. "Good" muscle health was defined as score of 2, and "poor" muscle health was defined as score of 0 to 1. Prospectively collected PROMs were analyzed at 2-week, 6-week, 3-month, 6-month, 1-year, and 2-year postoperative timepoints. The rate of and time to MCID achievement were compared among the cohorts. Bivariate analyses were performed to assess for correlations between psoas/paralumbar cross-sectional areas and change in PROM scores from baseline. RESULTS: The total cohort included 163 patients with minimum follow-up of 6 months and mean follow-up of 16.5 months. 40 patients (24.5%) were categorized into the low NTPA group, and 55 patients (33.7%) were categorized into the poor paralumbar muscle group. Low NTPA was associated with older age, lower BMI, and greater frequencies of Charlson Comorbidity Index (CCI) ≥1. Poor paralumbar muscle health was associated with older age, female sex, higher BMI, and CCI ≥1. There were no differences in rates of MCID achievement for any PROMs between low versus high NTPA groups or between poor versus good paralumbar groups. Low NTPA was associated with longer time to MCID achievement for ODI, VAS back, VAS leg, and SF-12 MCS. Poor paralumbar muscle health was associated with longer time to MCID achievement for VAS back, VAS leg, and SF-12 PCS. NTPA negatively correlated with change in VAS back (6-week, 12-week) and VAS leg (6-month). PL-CSA/BMI positively correlated with change in PROMIS-PF at 3 months follow-up. CONCLUSIONS: Among patients undergoing lumbar microdiscectomy, patients with worse muscle health grades achieved MCID at similar rates but required longer time to achieve MCID. Lower NTPA was weakly correlated with larger improvements in pain scores. PL-CSA/BMI positively correlated with change in PROMIS-PF. Our findings suggest that with regards to functional outcomes, patients with worse muscle health may take longer to recuperate postoperatively compared to those with better muscle health.

Emerging Racial Disparities in Outpatient Utilization of Total Joint Arthroplasty.

BACKGROUND: Racial and ethnic disparities within the field of total joint arthroplasty (TJA) have been extensively reported. To date, however, it remains unknown how these disparities have translated to the outpatient TJA (OP-TJA) setting. The purposes of this study were to compare relative OP-TJA utilization rates between White and Black patients from 2011-2019 and assess how these differences in utilization have evolved over time. METHODS: We conducted a retrospective review from 2011-2019 using the National Surgical Quality Improvement Program (NSQIP). Differences in the relative utilization of OP (same-day discharge) versus inpatient TJA between White and Black patients were assessed and trended over time. Multivariable logistic regressions were run to adjust for baseline patient factors and comorbidities. RESULTS: During the study period, Black patients were significantly less likely to undergo OP-TJA when compared to White patients (P < .001 for both outpatient total knee arthroplasty and outpatient total hip arthroplasty [OP-THA]). From 2011 to 2019, an emerging disparity was found in outpatient total knee arthroplasty and OP-THA utilization between White and Black patients (eg, White versus Black OP-THA: 0.4% versus 0.6% in 2011 compared with 10.2% versus 5.9% in 2019, Ptrend < .001). These results held in all adjusted analyses. CONCLUSION: In this study we found evidence of emerging and worsening racial disparities in the relative utilization of OP-TJA procedures between White and Black patients. These results highlight the need for early intervention by orthopaedic surgeons and policy makers alike to address these emerging inequalities in access to care before they become entrenched within our systems of orthopaedic care.

Risk of revision based on timing of corticosteroid injection prior to shoulder arthroplasty.

AIMS: Corticosteroid injections are often used to manage glenohumeral arthritis in patients who may be candidates for future total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (rTSA). In the conservative management of these patients, corticosteroid injections are often provided for symptomatic relief. The purpose of this study was to determine if the timing of corticosteroid injections prior to TSA or rTSA is associated with changes in rates of revision and periprosthetic joint infection (PJI) following these procedures. METHODS: Data were collected from a national insurance database from January 2006 to December 2017. Patients who underwent shoulder corticosteroid injection within one year prior to ipsilateral TSA or rTSA were identified and stratified into the following cohorts: < three months, three to six months, six to nine months, and nine to 12 months from time of corticosteroid injection to TSA or rTSA. A control cohort with no corticosteroid injection within one year prior to TSA or rTSA was used for comparison. Univariate and multivariate analyses were conducted to determine the association between specific time intervals and outcomes. RESULTS: In total, 4,252 patients were included in this study. Among those, 1,632 patients (38.4%) received corticosteroid injection(s) within one year prior to TSA or rTSA and 2,620 patients (61.6%) did not. On multivariate analysis, patients who received corticosteroid injection < three months prior to TSA or rTSA were at significantly increased risk for revision (odds ratio (OR) 2.61 (95% confidence interval (CI) 1.77 to 3.28); p < 0.001) when compared with the control cohort. However, there was no significant increase in revision risk for all other timing interval cohorts. Notably, Charlson Comorbidity Index ≥ 3 was a significant independent risk factor for all-cause revision (OR 4.00 (95% CI 1.40 to 8.92); p = 0.036). CONCLUSION: There is a time-dependent relationship between the preoperative timing of corticosteroid injection and the incidence of all-cause revision surgery following TSA or rTSA. This analysis suggests that an interval of at least three months should be maintained between corticosteroid injection and TSA or rTSA to minimize risks of subsequent revision surgery. Cite this article: Bone Joint J 2022;104-B(5):620-626.