Single-Level Anterolateral and Posterior Interbody Fusion Techniques are Associated with Equivalent Long-Term Lumbar Reoperations.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: This study compares reoperation rates and complications following single-level ALIF/LLIF and TLIF/PLIF. SUMMARY OF BACKGROUND DATA: Anterior lumbar interbody fusion (ALIF), lateral lumbar interbody fusion (LLIF), transforaminal lumbar interbody fusion (TLIF), and posterior lumbar interbody fusion (PLIF) are widely used for degenerative disc disease. Lumbar interbody fusions have high rates of reoperation primarily related to adjacent segment pathology and pseudarthrosis. METHODS: The PearlDiver database was queried for patients (2010-2021) who had single-level ALIF/LLIF or TLIF/PLIF with same-day, single-level posterior instrumentation. ALIF/LLIF were combined and similarly, TLIF/PLIF were combined, given how these operations are indistinguishable with Current Procedural Terminology (CPT) coding. All patients were followed for ≥2 years and excluded if they had spinal traumas, fractures, infections, or neoplasms prior to surgery. The two cohorts, ALIF/LLIF and TLIF/PLIF, were matched 1:1 based on age, sex, Elixhauser-Comorbidity Index (ECI), smoking status, and diabetes. The primary outcome was the incidence of all-cause subsequent lumbar operations. Secondary outcomes included 90-day surgical complications. RESULTS: After 1:1 matching, each cohort contained 14,070 patients. All-cause subsequent lumbar operations were nearly identical at 5-year follow-up (9.4% ALIF/LLIF vs. 9.5% TLIF/PLIF, P=0.91) (Table 2). Survival analysis using all-cause subsequent lumbar operations as the endpoint showed an equivalent 10-year survival rate of 86.0% (95%CI: 85.2-86.8) (Figure 1). Within 90 days, TLIF/PLIF had more infections (1.3% vs. 1.7%, P=0.007) and dural injuries (0.2% vs. 0.4%, P=0.001). There was no difference in wound dehiscence, hardware complications, or medical complications (Table 3). CONCLUSION: As utilized in real-world clinical practice, single-level anterolateral versus posterior approaches for interbody fusion have no effect on long term reoperation rates.

Clinical and Radiographic Outcomes of Percutaneous Chevron-Akin Osteotomies for the Correction of Hallux Valgus Deformity.

BACKGROUND: Hallux valgus is a common cause of pain and dysfunction of the foot, sometimes requiring surgical correction when conservative measures fail. Although there are many methods of correction, one of the newer techniques is minimally invasive chevron-Akin (MICA). The aim of the current study is to evaluate clinical and radiographic effectiveness of MICA and narcotic use in a large patient cohort. METHODS: All patients in this retrospective study were treated by a single fellowship-trained foot and ankle orthopaedic surgeon. Patient demographics were collected for all cases. Preoperative and postoperative intermetatarsal angle (IMA) and hallux valgus angle (HVA) were measured in all patients on weightbearing 3-views radiographs. The Foot Function Index (FFI) was obtained pre- and postoperatively at each visit. All patients were prescribed regular use of ibuprofen for 3 days with acetaminophen and oxycodone reserved for breakthrough pain. Use of narcotic pain medication was recorded. RESULTS: A total of 274 feet in 248 patients were included in the study. Overall, 87.9% were female and 12.1% were male. The mean preoperative IMA and HVA were 13.4 and 29.1 degrees, respectively. The postoperative IMA and HVA were 4.9 and 8.9 degrees, respectively. The mean FFI score part A was 92 preoperatively and 43 postoperatively. Patient satisfaction was 91.6%. The mean postoperative 5 mg oxycodone pill consumption was 2.2. CONCLUSION: MICA is good method to correct hallux valgus deformity with low postoperative narcotic use. LEVEL OF EVIDENCE: Level III, restrospective cohort study of a single surgeon practice.

Facet Violation With Percutaneous Pedicle Screw Placement: Impact of 3D Navigation and Facet Orientation.

Background: The gold standard for percutaneous pedicle screw placement is 2-dimensional (2D) fluoroscopy. Data are sparse on the accuracy of 3-dimensional (3D) navigation percutaneous screw placement in minimally invasive spine procedures. Objective: We sought to compare a single surgeon's percutaneous pedicle screw placement accuracy using 2D fluoroscopy versus 3D navigation, as well as to investigate the effect of facet orientation on facet violation when using 2D fluoroscopy. Methods: We conducted a retrospective radiographic study of consecutive cohort of patients who underwent percutaneous lumbar instrumentation using either 2D fluoroscopy or 3D navigation. All procedures were performed by a single surgeon at 2 academic institutions between 2011 and 2018. Radiographic measurement of screw accuracy was assessed using a postoperative computed tomographic scan. The primary outcome was facet violation, and secondary outcomes were endplate/tip breaches, the Gertzbein-Robbins classification for cortical breaches, and the Simplified Screw Accuracy grade. Statistical comparisons were made between screws placed using 2D fluoroscopy versus 3D navigation. Axial facet angles were also measured to correlate with facet violation rates. Results: In the 138 patients included, 376 screws were placed with fluoroscopy and 193 with navigation. Superior (unfused) level facet violation was higher with 2D fluoroscopy than with 3D navigation (9% vs 0.5%), which comprises the main cause for poor screw placement. Axial facet angles exceeding 45° at L4 and 60° at L5 were correlated with facet violations. Conclusion: This retrospective study found that 3D navigation is associated with lower facet violation rates in percutaneous lumbar pedicle screw placement when compared with 2D fluoroscopy. These findings suggest that 3D navigation may be of particular value when facet joints are coronally oriented.

Recoup From Home? Comparison of Relative Cost Savings for ACDF, Lumbar Discectomy, and Short Segment Fusion Performed in the Inpatient Versus Outpatient Setting.

STUDY DESIGN: Broad narrative review. OBJECTIVE: To review and summarize the current literature on the cost efficacy of performing ACDF, lumbar discectomy and short segment fusions of the lumbar spine performed in the outpatient setting. METHODS: A thorough review of peer- reviewed literature was performed on the relative cost-savings, as well as guidelines, outcomes, and indications for successfully implementing outpatient protocols for routine spine procedures. RESULTS: Primary elective 1-2 level ACDF can be safely performed in most patient populations with a higher patient satisfaction rate and no significant difference in 90-day reoperations and readmission rates, and a savings of 4000 to 41 305 USD per case. Lumbar discectomy performed through minimally invasive techniques has decreased recovery times with similar patient outcomes to open procedures. Performing lumbar microdiscectomy in the outpatient setting is safe, cheaper by as much as 12 934 USD per case and has better or equivalent outcomes to their inpatient counterparts. Unlike ACDF and lumbar microdiscectomy, short segment fusions are rarely performed in ASCs. However, with the advent of minimally invasive techniques paired with improved pain control, same-day discharge after lumbar fusion has limited clinical data but appears to have potential cost-savings up to 65-70% by reducing admissions. CONCLUSION: Performing ACDF, lumbar discectomy and short segment fusions in the outpatient setting is a safe and effective way of reducing cost in select patient populations.

Risk Factors for 30- and 90-Day Readmissions Due To Surgical Site Infection Following Posterior Lumbar Fusion.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: Identify the independent risk factors for 30- and 90-day readmission because of surgical site infection (SSI) in patients undergoing elective posterior lumbar fusion (PLF). SUMMARY OF BACKGROUND DATA: SSI is a significant cause of morbidity in the 30- and 90-day windows after hospital discharge. There remains a gap in the literature on independent risk factors for readmission because of SSI after PLF procedures. In addition, readmission for SSI after spine surgery beyond the 30-day postoperative period has not been well studied. METHODS: A retrospective analysis was performed on data from the 2012 to 2014 Healthcare Cost and Utilization Project Nationwide Readmissions Database. The authors identified 65,121 patients who underwent PLF. There were 191 patients (0.30%) readmitted with a diagnosis of SSI in the 30-day readmission window, and 283 (0.43%) patients readmitted with a diagnosis of SSI in the 90-day window. Baseline patient demographics and medical comorbidities were assessed. Bivariate and multivariate analyses were performed to examine the independent risk factors for readmission because of SSI. RESULTS: In the 30-day window after discharge, this study identified patients with liver disease, uncomplicated diabetes, deficiency anemia, depression, psychosis, renal failure, obesity, and Medicaid or Medicare insurance as higher risk patients for unplanned readmission with a diagnosis of SSI. The study identified the same risk factors in the 90-day window with the addition of diabetes with chronic complications, chronic pulmonary disease, and pulmonary circulation disease. CONCLUSIONS: Independent risk factors for readmission because of SSI included liver disease, uncomplicated diabetes, obesity, and Medicaid insurance status. These findings suggest that additional intervention in the perioperative workup for patients with these risk factors may be necessary to lower unplanned readmission because of SSI after PLF surgery.

Posterior Fusion for the Subaxial Cervical Spine: A Review of the Major Techniques.

Posterior fusion is a powerful tool to address pathology of the cervical spine, but the decision to fuse at any level should be made with great care. Various methods and constructs for posterior cervical fusion exist, all of which aim to restore the posterior tension band's ability to resist flexion forces. We identified articles regarding posterior fusion of the subaxial cervical spine in MEDLINE, Google Scholar, and PubMed. This article is a narrative review of earlier and current concepts regarding the posterior fusion of the subaxial cervical spine, including wiring, translaminar screws, lateral mass screws, and pedicle screws, weighing the strengths and weakness of the different modalities that the surgeon should bear in mind in creating operative plans individualized to patient pathology.

The most influential papers in direct anterior approach to total hip arthroplasty.

BACKGROUND: Citation analysis is a commonly used method for appraising the impact of academic publications within a particular field of study. A gap exists in the citation analysis literature with regard to the topic of direct anterior approach (DAA) hip arthroplasty. The purpose of this study is to identify the 50 most frequently cited publications related to this topic. METHODS: The Clarivate Analytics Web of Knowledge database was utilized to search for publications relating to DAA hip arthroplasty. The top 50 most cited articles that met inclusion criteria were recorded and reviewed for various metrics. RESULTS: The top 50 publications were cited a total of 3521 times, with an average of 86.3 total citations per year between 1980 and 2019. 47 of the 50 articles identified had been published since the year 2000. Cohort designs were the most common study type. CONCLUSIONS: This analysis provides insight into factors that characterize highly cited articles on the specific topic of DAA hip arthroplasty. These factors include higher levels of evidence, recent publication, and origin in the United States. Citations of DAA hip arthroplasty papers appear to be on the rise. The curation and analysis of this set of 50 articles will provide orthopaedic surgery clinicians, researchers, and residency program directors a guide for quickly isolating influential articles on the topic of DAA hip arthroplasty. This may serve as a quick reference for clinical decision-making, foundation for further research, and curriculum on DAA hip arthroplasty.

Risk Factors for 90-day Readmissions With Fluid and Electrolyte Disorders Following Posterior Lumbar Fusion.

STUDY DESIGN: Retrospective cohort study of the 2012 to 2014 Healthcare Cost and Utilization Project Nationwide Readmissions Database. OBJECTIVE: To identify risk factors for 30- and 90-day readmission due to fluid and electrolyte disorders following posterior lumbar fusion. SUMMARY OF BACKGROUND DATA: Thirty- and 90-day readmission rates are important quality and outcome measures for hospitals and physicians. These measures have been tied to financial penalties for abnormally high rates of readmission. Furthermore, complex and high cost surgeries have been increasingly reimbursed in the form of bundled disease resource group payments, where any treatment within 90-day postdischarge is covered within the original bundled payment scheme. METHODS: A total of 65,121 patients in the Healthcare Cost and Utilization Project Nationwide Readmissions Database met our inclusion criteria, of which 1128 patients (1.7%) were readmitted within 30 days, and 1669 patients (2.6%) were readmitted within 90 days due to fluid and electrolyte abnormalities. A bivariate analysis was performed to compare baseline characteristics between patients readmitted with fluid and electrolyte disorders and the remainder of the cohort. A multivariate regression analysis was then performed to identify independent risk factors for readmission due to fluid and electrolyte disorders at 30 and 90 days. RESULTS: The strongest independent predictors of 30-day readmissions were age ≥80 years, age 65 to 79 years, age 55 to 64 years, liver disease, and drug use disorder. The five strongest predictors of 90-day readmissions were age ≥80 years, age 65 to 79 years, age 55 to 64 years, liver disease, and fluid and electrolyte disorders. CONCLUSION: Patients with baseline liver disease, previously diagnosed fluid and electrolyte disorders, age older than 55 years, or drug use disorders are at higher risk for readmissions with fluid and electrolyte disorders following posterior lumbar fusion. Close monitoring of fluid and electrolyte balance in the perioperative period is essential to decrease complications and reduce unplanned readmissions. LEVEL OF EVIDENCE: 3.

Emerging Techniques in Diagnostic Imaging for Idiopathic Scoliosis in Children and Adolescents: A Review of the Literature.

Traditionally, full spine standing radiographs have been the reference standard for diagnostic imaging in adolescent idiopathic scoliosis (AIS). However, recent advances in diagnostic imaging have the potential to reduce radiation exposure and preserve the image quality and utility. Recent advances in diagnostic imaging for AIS include the EOS imaging system, the DIERS formetric scanner, and ultrasonography. Moderate to strong evidence is available to support the interobserver reliability and validity of each of these modalities, even compared with the reference standard imaging techniques. As such, these emerging techniques might prove beneficial in diagnosing and monitoring AIS and its progression, without high levels of continued radiation exposure. To understand the historical perspective and current state of advanced imaging techniques for AIS, a search of PubMed electronic database was conducted to identify studies that had examined these new techniques in the diagnosis of idiopathic scoliosis in children and adolescents.

Predicting In-Hospital Complications After Anterior Cervical Discectomy and Fusion: A Comparison of the Elixhauser and Charlson Comorbidity Indices.

OBJECTIVE: The objective of this study was to determine the ability of the Elixhauser Comorbidity Index (ECI) and Charlson Comorbidity Index (CCI) to predict postoperative complications after anterior cervical discectomy and fusion (ACDF). METHODS: This was a retrospective study of ACDF hospitalizations in the National Inpatient Sample from 2013 to 2014. The ECI and CCI were calculated, and patients who experienced postoperative complications were identified. The ability of these indexes to predict complications was compared using the c statistic (area under the receiver operating characteristic curve [AUC]). In addition, the CCI and ECI were compared with a base model that included age, sex, race, and primary payer. RESULTS: A total of 261,780 patients were included. Patients who experienced a complication were more often male (P < 0.0001) and older (P < 0.0001). They also had a higher comorbidity burden as assessed by both the ECI (P < 0.0001) and the CCI (P < 0.0001). The ECI was superior in predicting airway complications (AUC, 0.81 vs. 0.75; P < 0.0001), hemorrhagic anemia (AUC, 0.67 vs. 0.63; P = 0.0015), pulmonary embolism (AUC, 0.91 vs. 0.77; P < 0.0001), wound dehiscence (AUC, 0.80 vs. 0.55; P = 0.0080), sepsis (AUC, 0.87 vs. 0.82; P = 0.0001), and septic shock (AUC, 0.94 vs. 0.83; P < 0.0001). The CCI was not found to be superior to the ECI for predicting any complications. Both were excellent for predicting mortality (ECI AUC, 0.87; CCI AUC, 0.90). CONCLUSIONS: The ECI was superior to the CCI in predicting 6 of 15 complications in this study. Both are excellent tools for predicting mortality after ACDF.

Biomaterials in Spinal Implants: A Review.

The aim to find the perfect biomaterial for spinal implant has been the focus of spinal research since the 1800s. Spinal surgery and the devices used therein have undergone a constant evolution in order to meet the needs of surgeons who have continued to further understand the biomechanical principles of spinal stability and have improved as new technologies and materials are available for production use. The perfect biomaterial would be one that is biologically inert/compatible, has a Young's modulus similar to that of the bone where it is implanted, high tensile strength, stiffness, fatigue strength, and low artifacts on imaging. Today, the materials that have been most commonly used include stainless steel, titanium, cobalt chrome, nitinol (a nickel titanium alloy), tantalum, and polyetheretherketone in rods, screws, cages, and plates. Current advancements such as 3-dimensional printing, the ProDisc-L and ProDisc-C, the ApiFix, and the Mobi-C which all aim to improve range of motion, reduce pain, and improve patient satisfaction. Spine surgeons should remain vigilant regarding the current literature and technological advancements in spinal materials and procedures. The progression of spinal implant materials for cages, rods, screws, and plates with advantages and disadvantages for each material will be discussed.

The Effects of Liver Disease on Surgical Outcomes Following Adult Spinal Deformity Surgery.

BACKGROUND: As the prevalence of chronic liver disease continues to rise in the United States, understanding the effects of liver dysfunction on surgical outcomes has become increasingly important. The objective of this study was to assess the effects of chronic liver disease on 30-day complications following adult spinal deformity (ASD) surgery. METHODS: We performed a retrospective cohort study of 2337 patients in the 2008-2015 American College of Surgeons National Surgical Quality Improvement Program database who underwent corrective ASD surgery. Patients with liver disease were identified based on a Model for End-Stage Liver Disease-Na score ≥10. A univariate analysis was performed to compare 30-day postoperative complications between patients with and without liver disease. A multivariate regression analysis adjusting for differences in baseline patient characteristics was performed to identify complications that were associated with liver disease. RESULTS: Patients with liver disease had a significantly greater incidence of postoperative pulmonary complications (6.3% vs. 2.9%; P < 0.001), blood transfusion (34.6% vs. 24.0%; P < 0.001), sepsis (2.2% vs. 0.9%; P = 0.011), prolonged hospitalization (19.0% vs. 8.0%; P < 0.001), as well as any 30-day complication (45.4% vs. 29.4%; P < 0.001). The multivariate regression analysis identified liver disease as a risk factor for prolonged hospitalization (odds ratio [OR] 2.16; 95% confidence interval [CI] 1.64-2.84; P < 0.001), pulmonary complications (OR 1.78; 95% CI 1.16-2.74; P = 0.009), blood transfusion (OR 1.67; 95% CI 1.36-2.05; P < 0.001), and any 30-day complication (OR 1.43; 95% CI 1.15-1.77; P = 0.001). CONCLUSIONS: The multisystem pathophysiology of liver dysfunction predisposes patients to postoperative complications following ASD surgery. A multidisciplinary approach in surgical planning and preoperative optimization is needed to minimize liver disease-related complications and improve patient outcomes.

Applications of Machine Learning Using Electronic Medical Records in Spine Surgery.

Developments in machine learning in recent years have precipitated a surge in research on the applications of artificial intelligence within medicine. Machine learning algorithms are beginning to impact medicine broadly, and the field of spine surgery is no exception. Electronic medical records are a key source of medical data that can be leveraged for the creation of clinically valuable machine learning algorithms. This review examines the current state of machine learning using electronic medical records as it applies to spine surgery. Studies across the electronic medical record data domains of imaging, text, and structured data are reviewed. Discussed applications include clinical prognostication, preoperative planning, diagnostics, and dynamic clinical assistance, among others. The limitations and future challenges for machine learning research using electronic medical records are also discussed.