Assessing the variation and drivers of cost in 1-level lumbar fusion: a time-driven activity-based costing analysis.

BACKGROUND CONTEXT: As value-based health care arrangements gain traction in spine care, understanding the true cost of care becomes critical. Historically, inaccurate cost proxies have been used, including negotiated reimbursement rates or list prices. However, time-driven activity-based costing (TDABC) allows for a more accurate cost assessment, including a better understanding of the primary drivers of cost in 1-level lumbar fusion. PURPOSE: To determine the variation of total hospital cost, differences in characteristics between high-cost and non-high-cost patients, and to identify the primary drivers of total hospital cost in a sample of patients undergoing 1-level lumbar fusion. STUDY DESIGN/SETTING: Retrospective, multicenter (one academic medical center, one community-based hospital), observational study. PATIENT SAMPLE: A total of 383 patients undergoing elective 1-level lumbar fusion for degenerative spine conditions between November 2, 2021 and December 2, 2022. OUTCOME MEASURES: Total hospital cost of care (normalized); preoperative, intraoperative, and postoperative cost of care (normalized); ratio of most to least expensive 1-level lumbar fusion. METHODS: Patients undergoing a 1-level lumbar fusion between November 2, 2021 and December 2, 2022 were identified at two hospitals (one quaternary referral academic medical center and one community-based hospital) within our health system. TDABC was used to calculate total hospital cost, which was also broken up into: pre-, intra-, and postoperative timeframes. Operating surgeon and patient characteristics were also collected and compared between high- and non-high-cost patients. The correlation of surgical time and cost was determined. Multivariable linear regression was used to determine factors associated with total hospital cost. RESULTS: The most expensive 1-level lumbar fusion was 6.8x more expensive than the least expensive 1-level lumbar fusion, with the intraoperative period accounting for 88% of total cost. On average. the implant cost accounted for 30% of the total, but across the patient sample, the implant cost accounted for a range of 6% to 44% of the total cost. High-cost patients were younger (55 years [SD: 13 years] vs.63 years [SD: 13 years], p=.0002), more likely to have commercial health insurance (24 out of 38 (63%) vs. 181 out of 345 (52%), p=.003). There was a poor correlation between time of surgery (i.e., incision to close) and total overall cost (ρ: .26, p<.0001). Increase age (RC: -0.003 [95% CI: -0.006 to -0.000007], p=.049) was associated with decreased cost. Surgery by certain surgeons was associated with decreased total cost when accounting for other factors (p<.05). CONCLUSIONS: A large variation exists in the total hospital cost for patients undergoing 1-level lumbar fusion, which is primarily driven by surgeon-level decisions and preferences (e.g., implant and technology use). Also, being a "fast" surgeon intraoperatively does not mean your total cost is meaningfully lower. As efforts continue to optimize patient value through ensuring appropriate clinical outcomes while also reducing cost, spine surgeons must use this knowledge to lead, or at least be active participants in, any discussions that could impact patient care.

Post-operative Patient Portal Messaging is Associated With Return to the Emergency Department After Lumbar Spine Surgery.

STUDY DESIGN: Retrospective study. OBJECTIVE: To explore the association between patients undergoing lumbar spine surgery who message their care team via an electronic patient portal (EPP) post-operatively and emergency department (ED) visits within 90 days of surgery. SUMMARY OF BACKGROUND DATA: Secure patient messaging through electronic patient portals has grown over recent years. Despite its frequent utilization by patients to engage with their care team, its association with clinical outcomes remains unknown in spine surgery. METHODS: This study was approved by our Institutional Review Board. Inclusion criteria were adults who underwent single-stage lumbar spine surgery between January 2016-June 2023. Patients with incomplete information, multi-stage surgeries, and those who died within 90 days of surgery were excluded. Patient sociodemographic, surgical, hospital readmission, and patient-provider engagement data were collected. RESULTS: A total of 13,135 patients were included. A total of 1,711 patients (13%) had a post-operative ED visit, and 4,791 patients (36%) used the patient portal to send a message after surgery. Sending a post-operative patient message after undergoing lumbar spine surgery was associated with an increased likelihood of having an ED visit that does not lead to readmission (1.29 (1.10-1.53), P = 0.002). Patients with high school degrees were more likely to have an ED visit without readmission (1.33 (1.08-1.65), P = 0.008). CONCLUSION: Patients at a higher risk of presenting to the ED post-operatively should be identified and may benefit from additional counseling and access to the care team virtually to limit unnecessary healthcare utilization. Focusing on patients who reach out via EPP messaging post-operatively may be a good target patient group to address first. Future research is needed to investigate the possible health literacy and other socioeconomic barriers affecting these patients so that appropriate, more cost-effective resources can be utilized to avoid clinically unnecessary and costly ED visits.

What Happens to Sagittal Alignment Following Laminoplasty Versus Laminectomy and Fusion?

OBJECTIVE: Laminectomy and fusion (LF) and laminoplasty (LP) are 2 sucessful posterior decompression techniques for cervical myelo-radiculopathy. There is also a growing body of evidence describing the importance of cervical sagittal alignment (CSA) and its importance in outcomes. We investigated the difference between pre- and postoperative CSA parameters in and between LF or LP. Furthermore, we studied predictive variables associated with change in cervical mismatch (CM). METHODS: This is a retrospective cohort study of adults with cervical myeloradiculopathy in a single healthcare system. The primary outcomes are intra- and inter-cohort comparison of LF versus LP radiographic parameters at pre- and postoperative time points. A secondary multivariable analysis of predictive factors was performed evaluating factors predicting postoperative CM. RESULTS: Eighty nine patients were included; 38 (43%) had LF and 51 (57%) underwent LP. Both groups decreased in lordosis (LF 11.4° vs. 4.9°, P = 0.01; LP 15.2° vs. 9.1°, P < 0.001), increased in cSVA (LF 3.4 vs. 4.2 cm, P = 0.01; LP 3.2 vs. 4.2 cm, P < 0.001), and increased in CM (LF 22.0° vs. 28.5°, P = 0.02; LP 16.8° vs. 22.3°, P = 0.002). There were no significant differences in the postoperative CSA between groups. No significant predictors of change in pre- and postoperative CM were found. CONSLUSIONS: There were no significant pre-or postoperative differences following the 2 procedures, suggesting radiographic equipoise in well indicated patients. Across all groups, lordosis decreased, cSVA increased, and cervical mismatch increased. There were no predictive factors that led to change in cervical mismatch.

Avoiding Pitfalls in Adult Spinal Deformity.

To avoid the high rate of complications associated with the surgical management of adult spinal deformity, it is important to recognize and avoid three major pitfalls. The first is patient selection and determining which cases are appropriately indicated. The second is optimizing modifiable medical issues that can lead to a poor outcome, such as smoking, vitamin D deficiency, nutritional status, and poor bone quality. The third is optimizing surgical factors such as defining clinically appropriate, patient-specific target alignment goals as well as using techniques to avoid proximal junctional kyphosis and proximal junctional failure. It is important to describe these three key pitfalls that are commonly seen in the treatment of patients with adult spinal deformity and to describe methods to avoid them.

Inpatient opioid use varies by construct length among laminoplasty versus laminectomy and fusion patients.

Background: Laminoplasty (LP) and laminectomy and fusion (LF) are utilized to achieve decompression in patients with symptomatic degenerative cervical myelopathy (DCM). Comparative analyses aimed at determining outcomes and clarifying indications between these procedures represent an area of active research. Accordingly, we sought to compare inpatient opioid use between LP and LF patients and to determine if opioid use correlated with length of stay. Methods: Sociodemographic information, surgical and hospitalization data, and medication administration records were abstracted for patients >18 years of age who underwent LP or LF for DCM in the Mass General Brigham (MGB) health system between 2017 and 2019. Specifically, morphine milligram equivalents (MME) of oral and parenteral pain medication given after arrival in the recovery area until discharge from the hospital were collected. Categorical variables were analyzed using chi-squared analysis or Fisher exact test when appropriate. Continuous variables were compared using Independent samples t tests and Mann-Whitney U tests. Results: One hundred eight patients underwent LF, while 138 patients underwent LP. Total inpatient opioid use was significantly higher in the LF group (312 vs. 260 MME, p=.03); this difference was primarily driven by higher postoperative day 0 pain medication requirements. Furthermore, more LF patients required high dose (>80 MME/day) regimens. While length of stay was significantly different between groups, with LF patients staying approximately 1 additional day, postoperative day 0 MME was not a significant predictor of this difference. When operative levels including C2, T1, and T2 were excluded, the differences in total opioid use and average length of stay lost significance. Conclusions: Inpatient opioid use and length of stay were significantly greater in LF patients compared to LP patients; however, when constructs including C2, T1, T2 were excluded from analysis, these differences lost significance. Such findings highlight the impact of operative extent between these procedures. Future studies incorporating patient reported outcomes and evaluating long-term pain needs will provide a more complete understanding of postoperative outcomes between these 2 procedures.

Does Nasal Screening for Methicillin-Resistant Staphylococcus aureus (MRSA) Prevent Deep Surgical Site Infections for Elective Cervical Spinal Fusion?

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The objective of this study was to determine the relationship between nasal methicillin-resistant Staphylococcus aureus (MRSA) testing and surgical site infection (SSI) rates in the setting of primary posterior cervical instrumented spine surgery. SUMMARY OF BACKGROUND DATA: Preoperative MRSA screening and decolonization has demonstrated success for some orthopedic subspecialties in prevention of SSIs. Spine surgery, however, has seen varied results, potentially secondary to the anatomic and surgical heterogeneity of the patients included in prior studies. Given that prior research has demonstrated greater propensity for gram positive SSIs in the cervical spine, we sought to investigate if MRSA screening would be more impactful in the cervical spine. MATERIALS AND METHODS: Adult patients undergoing primary instrumented posterior cervical procedures from January 2015 to December 2019 were reviewed for MRSA testing <90 days before surgery, preoperative mupirocin, perioperative antibiotics, and SSI defined as operative incision and drainage (I&D) <90 days after surgery. Logistic regression modeling used SSI as the primary outcome, MRSA screening as primary predictor, and clinical and demographic factors as covariates. RESULTS: This study included 668 patients, of whom MRSA testing was performed in 212 patients (31.7%) and 6 (2.8%) were colonized with MRSA. Twelve patients (1.8%) underwent an I&D. On adjusted analysis, preoperative MRSA testing was not associated with postoperative I&D risk. Perioperative vancomycin similarly had no association with postoperative I&D risk. Notably, 6 patients (50%) grew methicillin sensitive Staphylococcus aureus from intraoperative cultures, with no cases of MRSA. CONCLUSIONS: There was no association between preoperative nasal MRSA screening and SSIs in primary posterior cervical instrumented procedures, nor was there any association between vancomycin or infection rate. Furthermore, there was a preponderance of gram positive infections but none caused by MRSA. Given these findings, the considerable cost and effort associated with MRSA testing in the setting of primary posterior cervical instrumentation may not be justified. Further research should investigate if higher-risk scenarios demonstrate greater utility of preoperative testing.

Magnetic Resonance Imaging Is Inadequate to Assess Cervical Sagittal Alignment Parameters.

STUDY DESIGN: Retrospective radiographic study. OBJECTIVE: To evaluate cervical sagittal alignment measurement reliability and correlation between upright radiographs and magnetic resonance imaging (MRI). SUMMARY OF BACKGROUND DATA: Cervical sagittal alignment (CSA) helps determine the surgical technique employed to treat cervical spondylotic myelopathy. Traditionally, upright lateral radiographs are used to measure CSA, but obtaining adequate imaging can be challenging. Utilizing MRI to evaluate sagittal parameters has been explored; however, the impact of positional change on these parameters has not been determined. METHODS: One hundred seventeen adult patients were identified who underwent laminoplasty or laminectomy and fusion for cervical spondylotic myelopathy from 2017 to 2019. Two clinicians independently measured the C2-C7 sagittal angle, C2-C7 sagittal vertical axis (SVA), and the T1 tilt. Interobserver and intraobserver reliability were assessed by intraclass correlation coefficient. RESULTS: Intraobserver and interobserver reliabilities were highly correlated, with correlations greater than 0.85 across all permutations; intraclass correlation coefficients were highest with MRI measurements. The C2-C7 sagittal angle was highly correlated between x-ray and MRI at 0.76 with no significant difference ( P =0.46). There was a weaker correlation with regard to C2-C7 SVA (0.48) and T1 tilt (0.62) with significant differences observed in the mean values between the 2 modalities ( P <0.01). CONCLUSIONS: The C2-C7 sagittal angle is highly correlated and not significantly different between upright x-ray and supine MRIs. However, cervical SVA and T1 tilt change with patient position. Since MRI does not accurately reflect the CSA in the upright position, upright lateral radiographs should be obtained to assess global sagittal alignment when planning a posterior-based cervical procedure.

Cervical Laminoplasty Versus Posterior Laminectomy and Fusion: Trends in Utilization and Evaluation of Complication and Revision Surgery Rates.

INTRODUCTION: Cervical laminoplasty (LP) and laminectomy with fusion (LF) are common operations used to treat cervical spondylotic myelopathy. Conflicting data exist regarding which operation provides superior patient outcomes while minimizing the risk of complications. This study evaluates the trends of LP compared with LF over the past decade in patients with cervical myelopathy and examines long-term revision rates and complications between the two procedures. METHODS: Patients aged 18 years or older who underwent LP or LF for cervical myelopathy from 2010 to 2019 were identified in the PearlDiver Mariner Database. Patients were grouped independently (LP versus fusion) and assessed for association with common medical and surgical complications. The primary outcome was the incidence of LP versus LF for cervical myelopathy over time. Secondary outcomes were revision rates up to 5 years postoperatively and the development of complications attributable to either surgery. RESULTS: In total, 1,420 patients underwent LP and 10,440 patients underwent LF. Rates of LP (10.5% to 13.7%) and LF (86.3% to 89.5%) remained stable, although the number of procedures nearly doubled from 865 in 2010 to 1,525 in 2019. On matched analysis, LP exhibited lower rates of wound complications, surgical site infections, spinal cord injury, dysphagia, cervical kyphosis, limb paralysis, incision and drainage/exploration, implant removal, respiratory failure, renal failure, and sepsis. Revision rates for both procedures at were not different at any time point. CONCLUSION: From 2010 to 2019, rates of LP have not increased and represent less than 15% of posterior-based myelopathy operations. Up to 5 years of follow-up, there were no differences in revision rates for LP compared with LF; however, LP was associated with fewer postoperative complications than LF. LEVEL OF EVIDENCE: Level III retrospective cohort study.

Perioperative Management of Spinal Cord Stimulators and Intrathecal Pain Pumps.

Spinal cord stimulators (SCSs) and intrathecal pain pumps (IPPs) are implantable devices used in the management of chronic pain or spasticity. Complications, such as infection, lead migration/failure, cerebrospinal fluid leak, neurologic injury, and other medical complications, can occur after placement and may require surgical intervention. Orthopaedic surgeons may encounter patients with these devices and should have a basic understanding of their function. In addition, they should be aware that patients may have residual stenosis or deformity contributing to their symptoms; thus, spine surgery referral may be indicated. If a patient with a SCS or IPP is undergoing revision spinal surgery, a preoperative discussion regarding retention versus removal of the device is imperative because indications for device retention, revision, and removal are complex. This review summarizes potential complications and intraoperative considerations concerning the proper perioperative management of SCSs/IPPs and will provide evidence-based data regarding management strategies for these devices.

Impact of insurance type on patient-reported outcome measures in patients with lumbar disc herniation.

BACKGROUND: Lumbar disc herniations (LDH) are among the most common spinal conditions. Despite increased appreciation for the importance of social determinants of health, the role that these factors play in patients with lumbar disc herniations is poorly defined. PURPOSE: To elucidate the association between insurance status and baseline patient reported outcome measures (PROMs) in the setting of lumbar disc herniations. STUDY DESIGN/SETTING: Retrospective cohort study PATIENT SAMPLE: Baseline patient-reported outcome measures (PROMS) were reviewed from 924 adult patients presenting for treatment of lumbar disc herniation within our institutional healthcare system (2015-2020). OUTCOME MEASURES: The Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Short Form 10a (PF10a), PROMIS Global-Mental, PROMIS Global-Physical, and visual analogue scale (VAS) for back and leg pain were assessed. METHODS: PROMIS scores at presentation were defined at the primary outcome and insurance status as the primary predictor. Differences in clinical and sociodemographic characteristics between our cohorts, stratified by insurance status, were evaluated using Wilcoxon rank-sum or chi-squared testing. We used multivariable negative binomial regression modeling to adjust for potential confounders including age, gender, race, language, ethnicity, comorbidity index, and median geospatial household income. RESULTS: We included 924 patients, with mean age of 58.4 +/- 15.2 years and 52.6% male prevalence. Patients insured through Medicaid were more likely to be Black, Hispanic, and non-English speaking patients compared with the commercially insured. The Charlson Comorbidity index was significantly higher in the Medicare group. Following adjusted analysis, patients with Medicaid insurance had significantly worse PF10a (IRR, 0.90, 95% CI 0.85-0.96), as well as PROMIS Global-Physical score (IRR 0.88, 95% CI 0.82-0.94), and VAS low back pain (IRR 1.20, 95% CI 1.04-1.40) when compared to the commercially insured. CONCLUSIONS: We encountered worse physical function, mental, and pain-related patient-reported outcomes for those with Medicaid insurance in a population of patients presenting for evaluation of lumbar disc herniation. These findings, including worse depression, anxiety, and higher axial back pain scores, merit further investigation into potential health system asymmetries, and should be accounted for by treating providers.

Surgical Intervention is Associated With Improvements in the ASIA Impairment Scale in Gunshot-induced Spinal Injuries of the Thoracic and Lumbar Spine.

STUDY DESIGN: Retrospective cohort study of patients from the National Spinal Cord Injury Statistical Center (NSCISC). OBJECTIVE: The aim was to compare the outcomes of patients with gunshot-induced spinal injuries (GSIs) treated operatively and nonoperatively. SUMMARY OF BACKGROUND DATA: The treatment of neurological deficits associated with gunshot wounds to the spine has been controversial. Treatment has varied widely, ranging from nonoperative to aggressive surgery. METHODS: Patient demographics, clinical information, and outcomes were extracted. Surgical intervention was defined as a "laminectomy, neural canal restoration, open reduction, spinal fusion, or internal fixation of the spine." The primary outcome was the American Spinal Injury Association (ASIA) Impairment Scale. Statistical comparisons of baseline demographics and neurological outcomes between operative and nonoperative cohorts were performed. RESULTS: In total, 961 patients with GSI and at least 1-year follow-up were identified from 1975 to 2015. The majority of patients were Black/African American (55.6%), male (89.7%), and 15-29 years old (73.8%). Of those treated surgically (19.7% of all patients), 34.2% had improvement in their ASIA Impairment Scale score at 1 year, compared with 20.6% treated nonoperatively. Overall, surgery was associated with a 2.0 [95% confidence interval (CI): 1.4-2.8] times greater likelihood of ASIA Impairment Scale improvement at 1 year. Specifically, benefit was seen in thoracic (odds ratio: 2.5; 95% CI: 1.4-4.6) and lumbar injuries (odds ratio: 1.7; 95% CI: 1.1-3.1), but not cervical injuries. CONCLUSIONS: While surgical indications are always determined on an individualized basis, in our review of GSIs, surgical intervention was associated with a greater likelihood of neurological recovery. Specifically, patients with thoracic and lumbar GSIs had a 2.5 and 1.7-times greater likelihood of improvement in their ASIA Impairment Scale score 1 year after injury, respectively, if they underwent surgical intervention.

Is It the Back or the Hip? Differentiating Lumbar Spine From Hip Pathologies: Key Points of Evaluation and Treatment.

Disorders of the hip and spine commonly coexist and are difficult to disentangle. When they do occur together, the pathology is often referred to as hip-spine syndrome. When hip-spine syndrome is suspected, it is critically important to properly identify the relative contributions that the hip and spine each provide to a patient's overall clinical presentation. To focus on the incorrect anatomic site would be a disservice to the patient. The interconnectivity of hip and spine pathology, the various clinical presentations of the most commonly seen hip and spine disorders, the broad differential and suggested workup that should be considered for such patients, the various treatment modalities available, and the clinical predictors and expected outcomes for patients with hip-spine syndrome are important factors for review.

Practice Variation Within a Single Institution in Management of Degenerative Spondylolisthesis.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The objective of this study was to assess variation in care for degenerative spondylolisthesis (DS) among surgeons at the same institution, to establish diagnostic and therapeutic variables contributing to this variation, and to determine whether variation in care changed over time. SUMMARY OF BACKGROUND DATA: Like other degenerative spinal disorders, DS is prone to practice variation due to the wide array of treatment options. Focusing on a single institution can identify more individualized drivers of practice variation by omitting geographic variability of demographics and socioeconomic factors. MATERIALS AND METHODS: We collected number of office visits, imaging procedures, injections, electromyography (EMG), and surgical procedures within 1 year after diagnosis. Multivariable logistic regression was used to determine predictors of surgery. The coefficient of variation (CV) was calculated to compare the variation in practice over time. RESULTS: Patients had a mean 2.5 (±0.6) visits, 1.8 (±0.7) imaging procedures, and 0.16 (±0.09) injections in the first year after diagnosis. Thirty-six percent (1937/5091) of patients had physical therapy in the 3 months after diagnosis. CV was highest for EMG (95%) and lowest for office visits (22%). An additional spinal diagnosis [odds ratio (OR)=3.99, P <0.001], visiting a neurosurgery clinic (OR=1.81, P =0.016), and diagnosis post-2007 (OR=1.21, P =0.010) were independently associated with increased surgery rates. The CVs for all variables decreased after 2007, with the largest decrease seen for EMG (132% vs. 56%). CONCLUSIONS: While there is variation in the management of patients diagnosed with DS between surgeons of a single institution, this variation seems to have gone down in recent years. All practice variables showed diminished variation. The largest variation and subsequent decrease of variation was seen in the use of EMG. Despite the smaller amount of variation, the rate of surgery has gone up since 2007.

Insurance Type is Associated with Baseline Patient-Reported Outcome Measures in Patients with Lumbar Stenosis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine if insurance type is associated with differences in baseline patient-reported outcome measures (PROMs) among patients with lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND DATA: PROMs are increasingly used as means to convey value. Prior research suggests that sociodemographic factors, including insurance type may influence these metrics, with patients who are more socioeconomi-cally disadvantaged reporting poorer baseline PROMs. Nonetheless, this association is yet to be evaluated among patients with spinal stenosis. METHODS: Six-hundred-eight patients with LSS were identified within a major academic health system. Their baseline Patient-Reported Outcomes Measurement Information System for physical function, pain, anxiety and depression, and visual analogue scale for low back and leg pain were analyzed. Wilcoxon rank-sum testing and chi-squared testing were utilized for descriptive nonadjusted comparisons. Negative binomial regression modeling was performed with PROMs considered as dependent variables, insurance type as the primary predictor, and all other factors (e.g., Charlson Comorbidity Index, age, gender, race, ethnicity, language spoken, and median geospatial household income) considered as covariates. RESULTS: The mean age of the cohort was 62.6 ± 14years with a female majority (50.7%). Patients with Medicaid insurance were younger, more likely to be Hispanic, and less likely to be English-speaking than those with commercial insurance or Medicare. Overall, patients with Medicaid insurance were found to have worse baseline PROMs across almost all domains, with the worst performance in Patient-Reported Outcomes Measurement Information System 10 physical global (incidence rate ration 0.88, 95% confidence interval 0.82-0.95) and mental function (incidence rate ration 0.85, 95% confidence interval 0.80-0.92). CONCLUSION: LSS patients insured through Medicaid have systematically worse baseline PROMs across almost all domains as compared to those with commercial insurance and Medicare, even after adjusting for confounders. These findings have broad ranging implications for research and healthcare policy, especially when using PROMs as measures of value.

ALIF Versus TLIF for L5-S1 Isthmic Spondylolisthesis: ALIF Demonstrates Superior Segmental and Regional Radiographic Outcomes and Clinical Improvements Across More Patient-reported Outcome Measures Domains.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The purpose of this study was to compare segmental and regional radiographic parameters between anterior interbody fusion (ALIF) and posterior interbody fusion (TLIF) for treatment of L5-S1 isthmic spondylolisthesis, and to assess for changes in these parameters over time. Secondarily, we sought to compare clinical outcomes via patient-reported outcome measures (PROMs) between techniques and within groups over time. SUMMARY OF BACKGROUND DATA: Isthmic spondylolistheses are frequently treated with interbody fusion via ALIF or TLIF approaches. Robust comparisons of radiographic and clinical outcomes are lacking. METHODS: We reviewed pre- and postoperative radiographs as well as Patient-Reported Outcomes Measurement Information System (PROMIS) elements for patients who received L5-S1 interbody fusions for isthmic spondylolisthesis in the Mass General Brigham (MGB) health system (2016-2020). Intraclass correlation testing was used for reliability assessments; Mann-Whitney U tests and Sign tests were employed for intercohort and intracohort comparative analyses, respectively. RESULTS: ALIFs generated greater segmental and L4-S1 lordosis than TLIF, both at first postoperative visit (mean 26 days [SE = 4]; 11.3° vs. 1.3°, P  < 0.001; 6.2° vs. 0.3°, P  = 0.005) and at final follow-up (mean 410days [SE = 45]; 9.6° vs. 0.2°, P < 0.001; 7.9° vs. 2.1°, P = 0.005). ALIF also demonstrated greater increase in disc height than TLIF at first (9.6 vs. 5.5 mm, P < 0.001) and final follow-up (8.7 vs. 3.6 mm, P < 0.001). Disc height was maintained in the ALIF group but decreased over time in the TLIF cohort (ALIF 9.6 vs. 8.7 mm, P = 0.1; TLIF 5.5 vs. 3.6 mm, P < 0.001). Both groups demonstrated improvements in Pain Intensity and Pain Interference scores; ALIF patients also improved in Physical Function and Global Health - Physical domains. CONCLUSION: ALIF generates greater segmental lordosis, regional lordosis, and restoration of disc height compared to TLIF for treatment of isthmic spondylolisthesis. Additionally, ALIF patients demonstrate significant improvements across more PROMs domains relative to TLIF patients.Level of Evidence: 3.

Nasal screening for methicillin-resistant Staphylococcus aureus does not reduce surgical site infection after primary lumbar fusion.

BACKGROUND CONTEXT: Preoperative methicillin-resistant Staphylococcus aureus (MRSA) testing and decolonization has demonstrated success for arthroplasty patients in surgical site infections (SSIs) prevention. Spine surgery, however, has seen varied results. PURPOSE: The purpose of this study was to determine the impact of nasal MRSA testing and operative debridement rates on surgical site infection after primary lumbar fusion. STUDY DESIGN/SETTING: Retrospective cohort study and/or Consolidated medical enterprise PATIENT SAMPLE: Adult patients undergoing primary instrumented lumbar fusions from January 2015 to December 2019 were reviewed. OUTCOME MEASURES: The primary outcome was incision and drainage performed in the operating room within 90 days of surgery. METHODS: MRSA testing <90-day's before surgery, mupirocin prescription <30-day's before surgery, perioperative antibiotics, and Elixhauser comorbidity index were collected for each subject. Bivariate analysis used Wilcoxon rank-sum testing and logistic regression modeling Multivariable logistic regression modeling assessed for associations with MRSA testing, intravenous vancomycin use, and I&D rate. RESULTS: The study included 1,884 patients for analysis, with mean age of 63.1 (SE 0.3) and BMI 29.5 (SE 0.1). MRSA testing was performed in 755 patients (40.1%) and was more likely to be performed in patients with lower Elixhauser index scores (OR 0.98, 95% CI 0.96-0.99, p=.021) on multivariable analysis. Vancomycin use increased significantly over time (OR 1.49 and/or year, 95% CI 1.3-1.8, p<.001) despite no change in mupirocin or I&D rates. MRSA testing, mupirocin prescriptions, perioperative parenteral vancomycin use, and intrawound vancomycin powder use had no impact on I&D rates. I&D risk was associated with higher BMI (OR 1.06, 95% CI 1.02-1.12, p=.009) and higher number of blood product units transfused (OR 1.23, 95% CI 1.03-1.46, p=.022). CONCLUSIONS: The present study demonstrates no impact on surgical I&D rates from the use of preoperative MRSA testing. Increased BMI and transfusions were associated with operative I&D rates for surgical site infection. As a result of the hospital directive, vancomycin use increased over time with no associated change in infection rates, underscoring the need for focused interventions, and engagement with antibiotic stewardship programs.

Open epidural blood patch to augment durotomy repair in lumbar spine surgery: surgical technique and cohort study.

BACKGROUND CONTEXT: Incidental durotomy during elective spine surgery is relatively common. While usually benign and self-limited, it can be associated with morbidity, increased cost, and medicolegal ramifications. Dural repair typically involves performing a primary closure using a suture or dural staple; repairs are then frequently augmented with a sealant, patch, or fat/fascial graft. Although primary repair of an incidental durotomy is standard practice, the ideal secondary sealant or augment choice remains unclear. A wide variety of commercially available dural sealant options exist, and while none have demonstrated consistent superiority, all are associated with single-use costs in the hundreds to thousands of dollars and have concerns regarding swelling, local inflammation, or short-lived dural adherence. PURPOSE: The goal of this study is to compare the results of dural repair augmentation using an open intraoperative epidural blood patch to a hydrogel technique. STUDY DESIGN/SETTING: Retrospective comparative cohort study at an academic referral center PATIENT SAMPLE: Adult patients undergoing lumbar spine surgery from March 2017 to January 2021 who sustained an incidental durotomy. Patients undergoing surgery for infection were excluded. OUTCOME MEASURES: The primary outcome was failure of the repair as determined by a return to the operating room for re-exploration of a persistent cerebrospinal fluid (CSF) leak within 30 days of the index procedure. A secondary outcome was the incidence of a postoperative positional headache, and if present, the method used to obtain resolution. The primary predictor was use of a suture and hydrogel technique ("hydrogel" group), or the use of an epidural blood patch ("EBP" group). METHODS: The method for applying an open epidural blood patch is presented in detail and involves primarily repairing the durotomy followed by allowing whole blood to pool and clot in the operative field until the durotomy is completely covered. This was compared with a group of patients undergoing secondary augmentation with commercially available hydrogel. In both groups, mechanical resistance to CSF leakage was confirmed with direct visualization and a Valsalva maneuver, respectively. Patients were instructed to remain flat until the morning after surgery. Chart review was used for data abstraction on preoperative, demographic, perioperative, and postoperative clinical factors. To compare between the hydrogel and EBP group, Wilcoxon rank-sum testing was used to test for non-parametric comparisons of means, and chi-square testing between binomial data. RESULTS: Of 732 patients during the study period, forty-eight patients met study criteria. Twenty-five patients were in the hydrogel group and 23 in the EBP group. Mean age was 69.3 years (standard error 1.3 years). Patients were predominantly female (n = 31, 64.6%) with a mean BMI of 29.5 (SE 0.8), with no significant baseline differences between the hydrogel and EBP groups. Two patients in the hydrogel group (8.0%) and two in the EBP group (8.7%) had mild positional headaches postoperatively that resolved without intervention within 24 hours. One (4.3%) patient in the EBP group had positional headaches following an initial headache-free period; this patient was returned to the operating room and no evidence of a persistent CSF leak was found despite meticulous exploration. CONCLUSIONS: An open, intraoperatively placed epidural blood patch may be an efficacious and cost-effective way to manage an incidental durotomy. This method merits further study as an allergy-free, no swell, cost-neutral method of dural repair augmentation.