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.

How Does the Severity of Neuroforaminal Compression in Cervical Radiculopathy Affect Outcomes of Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: This study is a retrospective cohort study. PURPOSE: This study aims to determine whether preoperative neuroforaminal stenosis (FS) severity is associated with motor function patient-reported outcome measures (PROMs) following anterior cervical discectomy and fusion (ACDF). OVERVIEW OF LITERATURE: Cervical FS can significantly contribute to patient symptoms. While magnetic resonance imaging (MRI) has been used to classify FS, there has been limited research into the impact of FS severity on patient outcomes. METHODS: Patients undergoing primary, elective 1-3 level ACDF for radiculopathy at a single academic center between 2015 and 2021 were identified retrospectively. Cervical FS was evaluated using axial T2-weighted MRI images via a validated grading scale. The maximum degree of stenosis was used for multilevel disease. Motor symptoms were classified using encounters at their final preoperative and first postoperative visits, with examinations ≤3/5 indicating weakness. PROMs were obtained preoperatively and at 1-year follow-up. Bivariate analysis was used to compare outcomes based on stenosis severity, followed by multivariable analysis. RESULTS: This study included 354 patients, 157 with moderate stenosis and 197 with severe stenosis. Overall, 58 patients (16.4%) presented with upper extremity weakness ≤3/5. A similar number of patients in both groups presented with baseline motor weakness (13.5% vs. 16.55, p =0.431). Postoperatively, 97.1% and 87.0% of patients with severe and moderate FS, respectively, experienced full motor recovery (p =0.134). At 1-year, patients with severe neuroforaminal stenosis presented with significantly worse 12-item Short Form Survey Physical Component Score (PCS-12) (33.3 vs. 37.3, p =0.049) but demonstrated a greater magnitude of improvement (Δ PCS-12: 5.43 vs. 0.87, p =0.048). Worse stenosis was independently associated with greater ΔPCS-12 at 1-year (ß =5.59, p =0.022). CONCLUSIONS: Patients with severe FS presented with worse preoperative physical health. While ACDF improved outcomes and conferred similar motor recovery in all patients, those with severe FS reported much better improvement in physical function.

Utilization of In-Hospital Orthopaedic Spine Consultations: Evaluating the Impact of Health Care Policy.

Access to specialty and private practice providers has been a divisive policy issue over the last decade, complicated by the conflict between a reduction in government-funded health care reimbursement and the need for health care providers to sustain a financially sound practice. This study evaluates the orthopedic spine consult service at an academic tertiary care center at 2 separate time points over a 5-year period to better understand the impact of decreasing orthopedic reimbursement rates and the increasing prevalence of federally supported medical insurance on the access to specialty care. In total 500 patients in 2017 and 480 patients in 2021 were included for the final analysis. A higher percentage of consults in 2021 came from the emergency department (74.0% versus 60.4%, P < 0.001); however, the emergency department saw fewer spinal cord injuries (11.9% versus 21.4%, P < 0.001), and the spinal cord injuries were less severe (3.1% versus 6.2% Association Impairment Scale A or B, P = 0.034). A smaller percentage of patients in 2021 went on to receive orthopedic spine surgery following consultation (35.2% versus 43.8%, P = 0.007), and those receiving surgery had an operation performed farther out from the initial consultation (4.73 versus 4.09 days, P < 0.001). Additionally, fewer patients with Medicare insurance (23.5% versus 30.8%) and more patients with Medicaid insurance (20.2% versus 12.4%) were seen in 2021 compared with 2017 (P = 0.003). Overall, this study found an increased proportion of Medicaid patients seen by the spine consult service but a decrease in the acuity of consults. Measures to improve access to health insurance under the Affordable Care Act have revealed the complexity of this issue in health care. This study's findings have demonstrated that while more patients did have insurance coverage following the Affordable Care Act, they still face a barrier to accessing outpatient orthopedic spine providers.

Radiographic and Patient-Reported Outcomes: Anteriorly Placed Transforaminal Lumbar Interbody Fusion Cage vs. Anterior Lumbar Interbody Fusion with Posterior Instrumentation.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: To compare outcomes in anteriorly placed transforaminal lumbar interbody fusions (TLIFs) and anterior lumbar interbody fusions (ALIFs). SUMMARY OF BACKGROUND DATA: TLIF and ALIF are surgical techniques that have become more prevalent in recent years. Although studies have compared the two, none have considered TLIFs with anteriorly placed cages, which may serve as a better comparison to ALIFs. MATERIALS AND METHODS: Patients undergoing TLIF or ALIF with posterior instrumentation from 2010-2020 at a tertiary care institution were retrospectively identified. TLIF cage position was assessed and those with anterior placement were included. Electronic medical records were reviewed to identify patient characteristics and patient-reported outcomes. Radiographic outcomes included posterior disc height (DH), lumbar lordosis (LL), sacral slope (SS), pelvic incidence (PI) and pelvic tilt (PT). Statistical analysis was performed to compare the two groups. RESULTS: Of the 351 patients, 108 had ALIF with posterior instrumentation and 207 had a TLIF. Preoperatively, TLIF patients had less LL (53.7° vs. 60.6°, P<0.001), SS (38.3° vs. 43.7°, P<0.001), and PI (60.1° vs. 66.1°, P<0.001), all of which remained significant at one-year and long-term follow-up (P<0.001). The TLIF group had less ∆DH (1.51° vs. 5.43°, P<0.001), ∆LL (1.8° vs. 2.97°, P=0.038), and ∆SL (0.18° vs. 4.40°, P<0.001) at one year postoperatively. At two to three years, ∆DH (P<0.001) and ∆SL (P=0.001) remained significant, but ∆LL (P=0.695) did not. Patients in the TLIF group had higher VAS-Back scores one year postoperatively (3.68 vs. 2.16, P=0.008) and experienced less improvement in ODI (-17.1 vs. -28.6, P=0.012) and VAS-Back (-2.67 vs. -4.50, P=0.008) compared to ALIF patients. CONCLUSIONS: Our findings suggest that ALIF with posterior instrumentation performed superiorly in radiographic outcomes and PROMs compared to anteriorly placed TLIFs. Anteriorly placed TLIF cages may not achieve the same results as those of ALIF cages.

The Impact of Unexpected Billing in Spine Surgery and How the Price Calculator Can Improve Patient Care.

STUDY DESIGN: Survey study. OBJECTIVE: The objective of this study was to determine the impact of unexpected in-network billing on the patient experience after spinal surgery. SUMMARY OF BACKGROUND DATA: The average American household faces difficulty paying unexpected medical bills. Although legislative efforts have targeted price transparency and rising costs, elective surgical costs continue to rise significantly. Patients are therefore sometimes still responsible for unexpected medical costs, the impact of which is unknown in spine surgery. METHODS: Patients who underwent elective spine surgery patients from January 2021 to January 2022 at a single institution were surveyed regarding their experience with the billing process. Demographic characteristics associated with unexpected billing situations, patient satisfaction, and financial distress, along with utilization and evaluation of the online price estimator, were collected. RESULTS: Of 818 survey participants, 183 (22.4%) received an unexpected in-network bill, and these patients were younger (56.7 vs. 63.4 y, P <0.001). Patients who received an unexpected bill were more likely to feel uninformed about billing (41.2% vs. 21.7%, P <0.001) and to report that billing impacted surgical satisfaction (53.8% vs. 19.1%, P <0.001). However, both groups reported similar satisfaction postoperatively (Likert >3/5: 86.0% vs. 85.5%, P =0.856). Only 35 (4.3%) patients knew of the price estimator's existence. The price estimator was reported to be very easy or easy (N=18, 78.2%) to understand and very accurate (N=6, 35.3%) or somewhat accurate (N=8, 47.1%) in predicting costs. CONCLUSIONS: Despite new regulations, a significant portion of patients received unexpected bills leading to financial distress and affecting their surgical experience. Although most patients were unaware of the price estimator, almost all patients who did know of it found it to be easy to use and accurate in cost prediction. Patients may benefit from targeted education efforts, including information on the price estimator to alleviate unexpected financial burden.

Utility of Seated Lateral Radiographs in the Diagnosis and Classification of Lumbar Degenerative Spondylolisthesis.

STUDY DESIGN: Retrospective cohort study. PURPOSE: Our goal was to determine which radiographic images are most essential for degenerative spondylolisthesis (DS) classification and instability detection. OVERVIEW OF LITERATURE: The heterogeneity in DS requires multiple imaging views to evaluate vertebral translation, disc space, slip angle, and instability. However, there are several restrictions on frequently used imaging perspectives such as flexion-extension and upright radiography. METHODS: We assessed baseline neutral upright, standing flexion, seated lateral radiographs, and magnetic resonance imaging (MRI) for patients identified with spondylolisthesis from January 2021 to May 2022 by a single spine surgeon. DS was classified by Meyerding and Clinical and Radiographic Degenerative Spondylolisthesis classifications. A difference of >10° or >8% between views, respectively, was used to characterize angular and translational instability. Analysis of variance and paired chi-square tests were utilized to compare modalities. RESULTS: A total of 136 patients were included. Seated lateral and standing flexion radiographs showed the greatest slip percentage (16.0% and 16.7%), while MRI revealed the lowest (12.2%, p <0.001). Standing flexion and lateral radiographs when seated produced more kyphosis (4.66° and 4.97°, respectively) than neutral upright and MRI (7.19° and 7.20°, p <0.001). Seated lateral performed similarly to standing flexion in detecting all measurement parameters and categorizing DS (all p >0.05). Translational instability was shown to be more prevalent when associated with seated lateral or standing flexion than when combined with neutral upright (31.5% vs. 20.2%, p =0.041; and 28.1% vs. 14.6%, p =0.014, respectively). There were no differences between seated lateral or standing flexion in the detection of instability (all p >0.20). CONCLUSIONS: Seated lateral radiographs are appropriate alternatives for standing flexion radiographs. Films taken when standing up straight do not offer any more information for DS detection. Rather than standing flexion-extension radiographs, instability can be detected using an MRI, which is often performed preoperatively, paired with a single seated lateral radiograph.

The impact of demineralized bone matrix characteristics on pseudarthrosis and surgical outcomes after posterolateral lumbar decompression and fusion.

Objectives: The objectives of our study were to compare the fusion rates and surgical outcomes of lumbar fusion surgery based on the (1) type of demineralized bone matrix (DBM) carrier allograft, (2) the presence/absence of a carrier, and (3) the presence of bone fibers in DBM. Methods: Patients >18 years of age who underwent single-level posterolateral decompression and fusion (PLDF) between L3 and L5 between 2014 and 2021 were retrospectively identified. We assessed bone grafts based on carrier type (no carrier, sodium hyaluronate carrier, and glycerol carrier) and the presence of bone fibers. Fusion status was determined based on a radiographic assessment of bony bridging, screw loosening, or change in segmental lordosis >5°. Analyses were performed to assess fusion rates and surgical outcomes. Results: Fifty-four patients were given DBM with a hyaluronate carrier, 75 had a glycerol carrier, and 94 patients were given DBM without a carrier. DBM carrier type, bone fibers, and carrier presence had no impact on 90-day readmission rates (P = 0.195, P = 0.099, and P = 1.000, respectively) or surgical readmissions (P = 0.562, P = 0.248, and P = 0.640, respectively). Multivariable logistic regression analysis found that type of carrier, presence of fibers (odds ratio [OR] = 1.106 [0.524-2.456], P = 0.797), and presence of a carrier (OR = 0.701 [0.370-1.327], P = 0.274) were also not significantly associated with successful fusion likelihood. Conclusion: Our study found no significant differences between DBM containing glycerol, sodium hyaluronate, or no carrier regarding fusion rates or surgical outcomes after single-level PLDF. Bone particulates versus bone fibers also had no significant differences regarding the likelihood of bony fusion.

Effect of Clinical and Radiographic Degenerative Spondylolisthesis Classification on Patient-reported Outcomes and Spinopelvic Parameters for Patients With Single-level L4-L5 Degenerative Spondylolisthesis After Lumbar Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To determine whether preoperative clinical and radiographic degenerative spondylolisthesis (CARDS) classification is associated with differences in patient-reported outcomes and spinopelvic parameters after posterior decompression and fusion for L4-L5 degenerative spondylolisthesis (DS). SUMMARY: The CARDS classification for lumbar DS, an alternative to the Meyerding system, considers additional radiographic findings such as disc space collapse and segmental kyphosis and stratifies DS into 4 radiographically distinct classes. Although CARDS has been shown to be a reliable and reproducible method for classifying DS, very few studies have assessed whether the CARDS types represent distinct clinical entities. PATIENTS AND METHODS: A retrospective cohort analysis was conducted on patients with L4-L5 DS who underwent posterior lumbar decompression and fusion. Changes in spinopelvic alignment and patient-reported outcomes measures, including recovery ratios and percentage of patients achieving the minimal clinically important difference, were compared among patients in each CARDS classification 1-year postoperatively using analysis of variance or Kruskal-Wallis H with Dunn post hoc analysis. Multiple linear regression determined whether CARDS groups significantly predicted patient-reported outcomes measures, lumbar lordosis (LL), and pelvic incidence-lumbar lordosis mismatch (PI-LL) while controlling for demographic and surgical characteristics. RESULTS: Preoperative type B spondylolisthesis predicted decreased improvement in "physical component and mental component score of the short form-12" compared with type A spondylolisthesis (ß-coefficient = -5.96, P = 0.031) at 1 year. Significant differences were found between CARDS groups with regards to ΔLL (A: -1.63 degrees vs B: -1.17 degrees vs C: 2.88 degrees vs D: 3.19 degrees, P = 0.010) and ΔPI-LL (A: 1.02 degrees vs B: 2.09 degrees vs C: -2.59 degrees vs D: -3.70 degrees, P = 0.012). Preoperative type C spondylolisthesis was found to predict increased LL (ß-coefficient = 4.46, P = 0.0054) and decreased PI-LL (ß-coefficient = -3.49, P = 0.025) at 1 year compared with type A spondylolisthesis. CONCLUSIONS: Clinical and radiographic outcomes differed significantly by preoperative CARDS classification type for patients undergoing posterior decompression and fusion for L4-L5 DS. LEVEL OF EVIDENCE: Level III.

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.

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.

Does a High Postoperative Opioid Dose Predict Chronic Use After ACDF?

OBJECTIVE: The purpose of this study is to determine if increased postoperative prescription opioid dosing is an isolated predictor of chronic opioid use after anterior cervical diskectomy and fusion (ACDF). METHODS: A retrospective cohort analysis of patients undergoing ACDF for degenerative diseases from 2016-2019 at a single institution was performed. Preoperative and postoperative opioid and benzodiazepine prescriptions, including morphine milligram equivalents (MMEs) and duration of use, were obtained from the Pennsylvania Prescription Drug Monitoring Program. Univariate analysis compared patient demographics and surgical factors across groups on the basis of postoperative opioid dose (high: MME ≥90, low: MME <90) and chronicity of use (chronic: ≥120 days or >10 prescriptions). Logistic regressions identified predictors of high opioid dose and chronic use. RESULTS: A total of 385 patients were included. Preoperative opioid tolerance and tobacco use were associated with high postoperative opioid dose and chronic usage. Younger age correlated with high-dose prescriptions. Increased body mass index and preoperative benzodiazepine use were associated with chronic opioid use. Chronic postoperative opioid use correlated with high-dose prescriptions, change in opioid prescribed, private pay scripts, and more than 1 prescriber and pharmacy. Logistic regression identified high postoperative opioid dose, opioid tolerance, increased body mass index, and no prior cervical surgery as predictors of chronic opioid use. Regression analysis determined younger age, increased medical comorbidities, and opioid tolerance to be predictors for high MME prescriptions. CONCLUSIONS: High postoperative opioid dose independently predicted chronic opioid use after ACDF regardless of preoperative opioid tolerance.

Risk Factors for Allograft Subsidence Following Anterior Cervical Discectomy and Fusion.

OBJECTIVE: The purpose this study was to precisely characterize patterns of allograft subsidence following anterior cervical discectomy and fusion (ACDF) utilizing computed tomography scans, determine risk factors for cervical allograft subsidence, and investigate the impact of subsidence on pseudarthrosis rates. METHODS: We performed a retrospective review of patients undergoing 1-to 3-level ACDF utilizing allograft interbodies with anterior plating between 2011 and 2019. Subsidence measurements were performed by 2 independent reviewers on computed tomography scans obtained 6 months postoperatively. Subsidence was then classified as mild if subsidence into the inferior and superior endplates were both ≤2 mm, moderate if the worst subsidence into the inferior- or superior endplate was between 2 and 4 mm, or severe if the worst subsidence into the inferior- or superior endplate was ≥4 mm. Multivariate analysis was performed to identify risk factors for the development of subsidence. RESULTS: We identified 98 patients (152 levels) for inclusion. A total of 73 levels demonstrated mild subsidence (≤2 mm), 61 demonstrated moderate subsidence (2-4 mm), and 18 demonstrated severe subsidence (≥4 mm). On multivariate analysis, risk factors for severe subsidence included excessive vertebral endplate resection and lower screw tip to vertebral body height ratio. Severe subsidence was associated with an increased rate of pseudarthrosis (94.1% vs. 13.6%) without an associated increase in reoperation rate. CONCLUSIONS: Following ACDF with allograft interbodies, 50% of interbodies will subside >2 mm and 10% of interbodies will subside >4 mm. Risk factors for severe subsidence should be mitigated to decrease the risk of pseudarthrosis.

Clinical Outcomes of Robotic Versus Freehand Pedicle Screw Placement After One-to Three-Level Lumbar Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The purpose of this study is to compare patient-reported outcome measures (PROMs) for patients undergoing one-to three-level lumbar fusion using robotically assisted vs freehand pedicle screw placement. METHODS: Patients who underwent either robotically assisted or freehand pedicle screw placement for one-to three-level lumbar fusion surgery from January 1, 2014 to August 31, 2020 at a single academic institution were identified. Propensity score matching was performed based on demographic variables. Clinical and surgical outcomes were compared between groups. Recovery Ratios (RR) and the proportion of patients achieving the minimally clinically important difference (%MCID) were calculated for Oswestry Disability Index, PCS-12, MCS-12, VAS Back, and VAS Leg at 1 year. Surgical outcomes included complication and revision rates. RESULTS: A total of 262 patients were included in the study (85 robotic and 177 freehand). No significant differences were found in ΔPROM scores, RR, or MCID between patients who underwent robotically assisted vs freehand screw placement. The rates of revision (1.70% freehand vs 1.18% robotic, P = 1.000) and complications (.57% freehand vs 1.18% robotic, P = .546) were not found to be statically different between the 2 groups. Controlling for demographic factors, procedure type (robotic vs freehand) did not emerge as a significant predictor of ΔPROM scores on multivariate linear regression analysis. CONCLUSIONS: Robotically assisted pedicle screw placement did not result in significantly improved clinical or surgical outcomes compared to conventional freehand screw placement for patients undergoing one-to three-level lumbar fusion.

The Impact of Preoperative Symptom Duration on Patient Outcomes After Posterior Cervical Decompression and Fusion.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVES: To determine if decreased preoperative symptom duration is associated with greater clinical improvement in function and myelopathic symptoms after posterior cervical decompression and fusion (PCDF). METHODS: All patients over age 18 who underwent primary PCDF for cervical myelopathy or myeloradiculopathy at a single institution between 2014 and 2020 were retrospectively identified. Patient demographics, surgical characteristics, duration of symptoms, and preoperative and postoperative patient reported outcomes measures (PROMs) including modified Japanese Orthopaedic Association (mJOA), Neck Disability Index (NDI), Visual Analogue Scale (VAS) Neck, VAS Arm, and SF-12 were collected. Univariate and multivariate analyses were performed to compare change in PROMs and minimum clinically important difference achievement (%MCID) between symptom duration groups (< 6 months, 6 months-2 years, > 2 years). RESULTS: Preoperative symptom duration groups differed significantly by sex and smoking status. Patients with < 6 months of preoperative symptoms improved significantly in all PROMs. Patients with 6 months-2 years of preoperative symptoms did not improve significantly in mJOA, Physical Component Scores (PCS), or NDI. Patients with > 2 years of symptoms failed to demonstrate significant improvement in mJOA, NDI, or Mental Component Scores (MCS). Univariate analysis demonstrated significantly decreased improvement in mJOA with longer symptom durations. Increased preoperative symptom duration trended toward decreased %MCID for mJOA and MCS. Regression analysis demonstrated that preoperative symptom duration of > 2 years relative to < 6 months predicted decreased improvement in mJOA and NDI and decreased MCID achievement for mJOA and MCS. CONCLUSION: Increased duration of preoperative symptoms (> 2 years) before undergoing PCDF was associated with decreased postoperative improvement in myelopathic symptoms.

MRSA Prophylaxis in Spine Surgery Decreases Postoperative Infections.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To compare infection rates before and after the implementation of a quality improvement protocol focused on methicillin-resistant Staphylococcus aureus (MRSA) screening and decolonization in patients undergoing lumbar fusion and/or decompression. SUMMARY OF BACKGROUND DATA: Prior studies have demonstrated MRSA infections comprise a sizable portion of SSIs. Additional studies are required to improve our understanding of the risks and benefits of MRSA decolonization with vancomycin prophylaxis. METHODS: A retrospective cohort analysis was conducted on patients who underwent spinal fusion or laminectomy before (2008-2011) and after (2013-2016) the implementation of an MRSA screening and treatment protocol. Odds ratios for MRSA, methicillin-sensitive Staphylococcus aureus (MSSA), and Vancomycin-resistant Enterococcus (VRE) infection before and after screening was calculated. Multivariate analysis assessed demographic characteristics as potential independent predictors of infection. RESULTS: A total of 8425 lumbar fusion and 2558 lumbar decompression cases met inclusion criteria resulting in a total cohort of 10,983 patients. There was a significant decrease in the overall rate of infections ( P <0.001), MRSA infections ( P <0.001), and MSSA infections ( P <0.001) after protocol implementation. Although VRE infections after protocol implementation were not significantly different ( P =0.066), VRE rates as a percentage of all postoperative infections were substantially increased (0 vs. 3.36%, P =0.007). On multivariate analysis, significant predictors of the infection included younger age (OR=0.94[0.92-0.95]), shorter length of procedure (OR=1.00[0.99-1.00]), spinal fusion (OR=18.56[8.22-53.28]), higher ASA class (OR=5.49[4.08-7.44]), male sex (OR=1.61[1.18-2.20]), and history of diabetes (OR=1.58[1.08-2.29]). CONCLUSION: The implemented quality improvement protocol demonstrated that preoperative prophylactically treating MRSA colonized patients decreased the rate of overall infections, MSSA infections, and MRSA infections. In addition, younger age, male sex, diabetic status, greater ASA scores, and spinal fusions were risk factors for postoperative infection.

Single-level Lumbar Fusion Versus Total Joint Arthroplasty: A Comparison of 1-year Outcomes.

INTRODUCTION: Primary hip and knee arthroplasty represent two of the most successful orthopaedic surgical interventions in the past century. Similarly, lumbar fusion (LF) remains a valuable, evidence-based option to relieve pain and disability related to spinal degenerative conditions. This study evaluates the relative improvements in 1-year health-related quality of life (HRQOL) measures among patients undergoing primary single-level LF, primary total hip arthroplasty (THA), and primary total knee arthroplasty (TKA). METHODS: Patients older than 18 years who underwent primary single-level posterior LF (posterolateral decompression and fusion with or without transforaminal lumbar interbody fusion, involving any single lumbar level), TKA, and THA at a single academic institution were retrospectively identified. Patient demographics and surgical characteristics were collected. HRQOL measures were collected preoperatively and at 1-year postoperative time point including Short-Form 12 Physical Component Score (PCS) and Mental Component Score (MCS) along with subspecialty-specific outcomes. RESULTS: A total of 2,563 patients were included (346 LF, 1,035 TKA, and 1,182 THA). Change in MCS-12 and PCS-12 after LF did not vary markedly by preoperative diagnosis. LF patients had a significantly lower preoperative MCS-12 (LF: 50.8, TKA: 53.9, THA: 52.9, P < 0.001), postoperative MCS-12 (LF: 52.5, TKA: 54.8, THA: 54.5, P < 0.001), postoperative PCS-12 (LF: 40.1, TKA: 44.0, THA: 43.9, P < 0.001), ΔPCS-12 (LF: 7.9, TKA: 10.8, THA: 11.9, P < 0.001), and PCS-12 recovery ratio (LF: 10.7%, TKA: 15.1%, THA 16.6%, P < 0.001) compared with TKA and THA patients. In regression analysis, both TKA and LF were found to be independently associated with a smaller ΔPCS-12 improvement (TKA: ß = -1.36, P = 0.009; LF: ß = -4.74, P < 0.001) compared with THA. TKA (ß = -1.42, P = 0.003) was also independently associated with a smaller ΔMCS-12 improvement compared with THA. CONCLUSIONS: Patients undergoing single-level LF, TKA, and THA demonstrate notable improvements in HRQOL outcomes at 1 year postoperatively compared with preoperative baseline scores. The greatest improvements were found among THA patients, followed subsequently by TKA and LF patients. Both LF and TKA were independently associated with markedly less improvement in physical disability at 1 year postoperatively compared with THA. STUDY DESIGN: Retrospective Cohort Study.

Recent Trends in Spine Topics on the Orthopaedic In-Training Examination.

INTRODUCTION: The Orthopaedic In-Training Examination (OITE) is an important metric for orthopaedic residents and residency programs to gauge a resident's orthopaedic knowledge. Because the OITE is correlated with the likelihood of passing part I of the American Board of Orthopaedic Surgery, greater emphasis is being placed on the examination. However, a detailed look at the questions most likely to appear on the spine subsection of the OITE has not been done in the past decade. METHODS: Digital copies of the OITEs during the years 2017 through 2021 were obtained online through the "ResStudy" program within the American Academy of Orthopaedic Surgeons Online Learning Platform. All spine-related questions were categorized into five different categories including type of spine question (knowledge-based, diagnosis, or evaluation/management), anatomical region, imaging modality provided, subject matter, and referenced journal or textbook. The total number and likelihood of each question type to appear on the OITE were defined as mean and percentage of the total number of spine questions, respectively. RESULTS: A total of 139 spine questions were identified on the OITE during the years 2017 to 2021. The most common type of spine questions were evaluation/management (N = 65) and knowledge-based questions. We identified lumbar (N = 45), cervical (N = 42), thoracolumbar (N = 13), and thoracic (N = 12) as the most commonly tested anatomical regions. Spinal trauma (N = 26), disk disease/disk herniation (N = 16), postoperative complications (N = 15), and scoliosis/sagittal balance (N = 15) were the most commonly tested material. Spine (N = 54) was almost two times more likely to be referenced as the source for the tested material compared with other journals or textbooks. CONCLUSIONS: Understanding the spine topics most likely to appear on the OITE may allow orthopaedic residents and residency programs to supplement educational objectives toward the highest yield spine topics and journals.

Does displacement of cervical and thoracolumbar dislocation-translation injuries predict spinal cord injury or recovery?

OBJECTIVE: For patients with cervical and thoracolumbar AO Spine type C injuries, the authors sought to 1) identify whether preoperative vertebral column translation is predictive of a complete spinal cord injury (SCI) and 2) identify whether preoperative or postoperative vertebral column translation is predictive of neurological improvement after surgical decompression. METHODS: All patients who underwent operative treatment for cervical and thoracolumbar AO Spine type C injuries at the authors' institution between 2006 and 2021 were identified. CT and MRI were utilized to measure vertebral column translation in millimeters prior to and after surgery. A receiver operating characteristic (ROC) curve was generated to predict the probability of sustaining a complete SCI on the basis of the amount of preoperative vertebral column translation. ROC curves were then used to predict the probability of neurological recovery on the basis of preoperative and postoperative vertebral column translation. RESULTS: ROC analysis of 67 patients identified 6.10 mm (area under the curve [AUC] 0.77, 95% CI 0.650-0.892) of preoperative vertebral column translation as predictive of complete SCI. Additionally, ROC curve analysis found that 10.4 mm (AUC 0.654, 95% CI 0.421-0.887) of preoperative vertebral column translation was strongly predictive of no postoperative neurological improvement. Residual postoperative vertebral column translation after fracture reduction and instrumentation had no predictive value on neurological recovery (AUC 0.408, 95% CI 0.195-0.622). CONCLUSIONS: For patients with cervical and thoracolumbar AO Spine type C injuries, the amount of preoperative vertebral column translation is highly predictive of complete SCI and the likelihood of postoperative neurological recovery.

Trends in Single-Level Lumbar Fusions Over the Past Decade Using a National Database.

OBJECTIVE: To compare rates of different fusion techniques using a nationwide database over the last decade and identify differences in complications and readmissions based on fusion technique. METHODS: All elective, single-level lumbar fusions performed by orthopaedic surgeons from 2011 to 2020 were identified from the American College of Surgeons National Surgical Quality Improvement Program. Rates of lumbar fusion technique posterolateral decompression and fusion [PLDF], combined transforaminal lumbar interbody fusion and PLDF, anterior lumbar or lateral lumbar interbody fusion [ALIF/LLIF], and combined ALIF/LLIF and PLDF were recorded, and 30-day complications and readmissions were compared. Secondary analysis included multiple logistic regression to determine independent predictors of each outcome. RESULTS: Inclusion criteria were met by 28,413 fusions: 8749 (30.8%) PLDFs, 11,973 (42.1%) transforaminal lumbar interbody fusions, 4769 (16.8%) ALIF/LLIFs, and 2922 (10.3%) combined ALIF/LLIF and PLDFs. The number of fusions increased over time with 1227 fusions performed in 2011 and 3958 fusions performed in 2019. Interbody fusions also increased over time with a subsequent decrease in PLDFs (39.0% in 2011, 25.2% in 2020). Patients were more likely to be discharged home over the course of the decade (85.4% in 2011, 95.0% in 2020). No difference was observed between the techniques regarding complications or readmissions. The modified 5-item frailty index was predictive of complications (odds ratio, 2.05; P = 0.001) and readmissions (odds ratio, 2.61; P < 0.001). CONCLUSIONS: Lumbar fusions have continued to increase over the last decade with an increasing proportion of interbody fusions. Complications and readmissions appear to be driven by patient comorbidity and not fusion technique.

Does Age and Medicare Status Affect Clinical Outcomes in Patients Undergoing Anterior Cervical Discectomy and Fusion?

OBJECTIVE: The objective of this study was to determine if Medicare status and age affect clinical outcomes following anterior cervical discectomy and fusion. METHODS: Patients who underwent cervical discectomy and fusion between 2014 and 2020 with complete preoperative and 1-year postoperative patient-reported outcome measures (PROMs) were grouped based on Medicare status and age: no Medicare under 65 years (NM < 65), Medicare under 65 years (M < 65), no Medicare 65 years or older (NM ≥ 65), and Medicare 65 years or older (M ≥ 65). Multivariate regression for ΔPROMs (Δ: postoperative minus preoperative) controlled for confounding differences between groups. Significant was set at P < 0.05. RESULTS: A total of 1288 patients were included, with each group improving in the visual analog score (VAS) Neck (all, P < 0.001), VAS Arm (M < 65: P = 0.003; remaining groups: P < 0.001), and Neck Disability Index (M < 65: P = 0.009; remaining groups: P < 0.001) following surgery. Only M < 65 did not significantly improve in the Physical Component Score (PCS-12) and modified Japanese Orthopaedic Association (mJOA) score (P = 0.256 and P = 0.092, respectively). When comparing patients under 65 years, non-Medicare patients had better preoperative PCS-12 (P < 0.001), Neck Disability Index (P < 0.001), and modified Japanese Orthopaedic Association (P < 0.001), as well as better postoperative values for all PROMs (P < 0.001), but there were no differences in ΔPROMs. Multivariate analysis identified M < 65 to be an independent predictor of decreased improvement in ΔPCS-12 (ß = -4.07, P = 0.015), ΔVAS Neck (ß = 1.17, P = 0.010), and ΔVAS Arm (ß = 1.15, P = 0.025) compared to NM < 65. CONCLUSIONS: Regardless of age and Medicare status, all patients undergoing cervical discectomy and fusion had significant clinical improvement postoperatively. However, Medicare patients under age 65 have a smaller magnitude of improvement in PROMs.