Basivertebral Nerve Radiofrequency Ablation (Intracept): Procedural Technique.

Intraosseous basivertebral nerve ablation is indicated for the treatment of chronic vertebrogenic low back pain with failure of at least 6 months of conservative treatment. This article details patient positioning and setup, step-by-step instructions for the procedure, and postoperative management. Pearls and pitfalls are also discussed. In addition, an instructional procedure video accompanies this paper and can be found online (at https://vimeo.com/791578426/de0e90cfbe).

The attainment of a patient acceptable symptom state in patients undergoing revision spine fusion.

INTRODUCTION: Revision lumbar fusion is most commonly due to nonunion, adjacent segment disease (ASD), or recurrent stenosis, but it is unclear if diagnosis affects patient outcomes. The primary aim of this study was to assess whether patients achieved the patient acceptable symptom state (PASS) or minimal clinically important difference (MCID) after revision lumbar fusion and assess whether this was influenced by the indication for revision. METHODS: We retrospectively identified all 1-3 level revision lumbar fusions at a single institution. Oswestry Disability Index (ODI) was collected at preoperative, three-month postoperative, and one-year postoperative time points. The MCID was calculated using a distribution-based method at each postoperative time point. PASS was set at the threshold of ≤ 22. RESULTS: We identified 197 patients: 56% with ASD, 28% with recurrent stenosis, and 15% with pseudarthrosis. The MCID for ODI was 10.05 and 10.23 at three months and one year, respectively. In total, 61% of patients with ASD, 52% of patients with nonunion, and 65% of patients with recurrent stenosis achieved our cohort-specific MCID at one year postoperatively with ASD (p = 0.78). At one year postoperatively, 33.8% of ASD patients, 47.8% of nonunion patients, and 37% of patients with recurrent stenosis achieved PASS without any difference between indication (p = 0.47). CONCLUSIONS: The majority of patients undergoing revision spine fusion experience significant postoperative improvements regardless of the indication for revision. However, a large proportion of these patients do not achieve the patient acceptable symptom state. While revision spine surgery may offer substantial benefits, these results underscore the need to manage patient expectations.

Meta-Analysis of Genome-Wide Association Studies Reveals Genetic Mechanisms of Supraventricular Arrhythmias.

BACKGROUND: Substantial data support a heritable basis for supraventricular tachycardias, but the genetic determinants and molecular mechanisms of these arrhythmias are poorly understood. We sought to identify genetic loci associated with atrioventricular nodal reentrant tachycardia (AVNRT) and atrioventricular accessory pathways or atrioventricular reciprocating tachycardia (AVAPs/AVRT). METHODS: We performed multiancestry meta-analyses of genome-wide association studies to identify genetic loci for AVNRT (4 studies) and AVAP/AVRT (7 studies). We assessed evidence supporting the potential causal effects of candidate genes by analyzing relations between associated variants and cardiac gene expression, performing transcriptome-wide analyses, and examining prior genome-wide association studies. RESULTS: Analyses comprised 2384 AVNRT cases and 106 489 referents, and 2811 AVAP/AVRT cases and 1,483 093 referents. We identified 2 significant loci for AVNRT, which implicate NKX2-5 and TTN as disease susceptibility genes. A transcriptome-wide association analysis supported an association between reduced predicted cardiac expression of NKX2-5 and AVNRT. We identified 3 significant loci for AVAP/AVRT, which implicate SCN5A, SCN10A, and TTN/CCDC141. Variant associations at several loci have been previously reported for cardiac phenotypes, including atrial fibrillation, stroke, Brugada syndrome, and electrocardiographic intervals. CONCLUSIONS: Our findings highlight gene regions associated with ion channel function (AVAP/AVRT), as well as cardiac development and the sarcomere (AVAP/AVRT and AVNRT) as important potential effectors of supraventricular tachycardia susceptibility.

Evaluation of perioperative care and drivers of cost in geriatric thoracolumbar trauma.

Introduction: As the population of elderly patients continues to rise, the number of these individuals presenting with thoracolumbar trauma is expected to increase. Research question: To investigate thoracolumbar fusion outcomes for patients with vertebral fractures as stratified by decade. Secondarily, we examined the variability of cost across age groups by identifying drivers of cost of care. Materials and methods: We queried the United States Nationwide Inpatient Sample(NIS) for adult patients undergoing spinal fusion for thoracolumbar fractures between 2012 and 2017. Patients were stratified by decade 60-69(sexagenarians), 70-79(septuagenarians) and 80-89(octogenarians). Bivariable analysis followed by multivariable regression was performed to assess independent predictors of length of stay(LOS), hospital cost, and discharge disposition. Results: A total of 2767 patients were included, of which 46%(N = 1268) were sexagenarians, 36% septuagenarians and 18%(N = 502) octogenarians. Septuagenarians and octogenarians had shorter LOS compared to sexagenarians(ß = -0.88 days; p = 0.012) and(ß = -1.78; p < 0.001), respectively. LOS was reduced with posterior approach(-2.46 days[95% CI: 3.73-1.19]; p < 0.001), while Hispanic patients had longer LOS(+1.97 [95% CI: 0.81-3.13]; p < 0.001). Septuagenarians had lower total charges $12,185.70(p = 0.040), while the decrease in charges in octogenarians was more significant, with a decrease of $26,016.30(p < 0.001) as compared to sexagenarians. Posterior approach was associated with a decrease of $24,337.90 in total charges(p = 0.026). Septuagenarians and octogenarians had 1.72 higher odds(p < 0.001) and 4.16 higher odds(p < 0.001), respectively, of discharge to a skilled nursing facility. Discussion and conclusions: Healthcare utilization in geriatric thoracolumbar trauma is complex. Cost reductions in the acute hospital setting may be offset by unaccounted costs after discharge. Further research into this phenomenon and observed racial/ethnic disparities must be pursued.

Preoperative Oswestry Disability Index Should not be Utilized to Determine Surgical Eligibility for Patients Requiring Lumbar Fusion for Degenerative Lumbar Spine Disease.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To evaluate how preoperative Oswestry Disability Index (ODI) thresholds might affect minimal clinically important difference (MCID) achievement following lumbar fusion. SUMMARY OF BACKGROUND DATA: As payers invest in alternative payment models, some are suggesting threshold cutoffs of patient-reported outcomes (PROMs) in reimbursement approvals for orthopedic procedures. The feasibility of this has not been investigated in spine surgery. MATERIALS/METHODS: We included all adult patients undergoing one to three-level primary lumbar fusion at a single urban tertiary academic center from 2014 to 2020. ODI was collected preoperatively and one year postoperatively. We implemented theoretical threshold cutoffs at increments of 10. MCID was set at 14.3. The percent of patients meeting MCID were determined among patients "approved" or "denied" at each threshold. At each threshold, the positive predictive value (PPV) for MCID attainment was calculated. RESULTS: A total 1368 patients were included and 62.4% (N=364) achieved MCID. As the ODI thresholds increased, a greater percent of patients in each group reached the MCID. At the lowest ODI threshold, 6.58% (N=90) of patients would be denied, rising to 20.2%, 39.5%, 58.4%, 79.9%, and 91.4% at ODI thresholds of 30, 40, 50, 60, and 70, respectively. The PPV increased from 0.072 among patients with ODI>20 to 0.919 at ODI>70. The number of patients denied a clinical improvement in the denied category per patient achieving the MCID increased at each threshold (ODI>20: 1.96; ODI>30: 2.40; ODI>40: 2.75; ODI>50: 3.03; ODI>60: 3.54; ODI>70: 3.75). CONCLUSION: Patients with poorer preoperative ODI are significantly more likely to achieve MCID following lumbar spine fusion at all ODI thresholds. Setting a preoperative ODI threshold for surgical eligibility will restrict access to patients who may benefit from spine fusion despite ODI>20 demonstrating the lowest predictive value for MCID achievement. LEVEL OF EVIDENCE: 3.

Does Operative Level Impact Dysphagia Severity After Anterior Cervical Discectomy and Fusion?: A Multicenter Prospective Analysis.

STUDY DESIGN: Prospective multicenter cohort study. OBJECTIVE: To explore the association between operative level and postoperative dysphagia after anterior cervical discectomy and fusion (ACDF). BACKGROUND: Dysphagia is common after ACDF and has several risk factors, including soft tissue edema. The degree of prevertebral soft tissue edema varies based on the operative cervical level. However, the operative level has not been evaluated as a source of postoperative dysphagia. PATIENTS AND METHODS: Adult patients undergoing elective ACDF were prospectively enrolled at 3 academic centers. Dysphagia was assessed using the Bazaz Questionnaire, Dysphagia Short Questionnaire, and Eating Assessment Tool-10 (EAT-10) preoperatively and at 2, 6, 12, and 24 weeks postoperatively. Patients were grouped based on the inclusion of specific surgical levels in the fusion construct. Multivariable regression analyses were performed to evaluate the independent effects of the number of surgical levels and the inclusion of each particular level on dysphagia symptoms. RESULTS: A total of 130 patients were included. Overall, 24 (18.5%) patients had persistent postoperative dysphagia at 24 weeks and these patients were older, female, and less likely to drink alcohol. There was no difference in operative duration or dexamethasone administration. Patients with persistent dysphagia were significantly more likely to have C4-C5 included in the fusion construct (62.5% vs . 34.9%, P = 0.024) but there were no differences based on the inclusion of other levels. On multivariable regression, the inclusion of C3-C4 or C6-C7 was associated with more severe EAT-10 (ß: 9.56, P = 0.016 and ß: 8.15, P = 0.040) and Dysphagia Short Questionnaire (ß: 4.44, P = 0.023 and (ß: 4.27, P = 0.030) at 6 weeks. At 12 weeks, C3-C4 fusion was also independently associated with more severe dysphagia (EAT-10 ß: 4.74, P = 0.024). CONCLUSION: The location of prevertebral soft tissue swelling may impact the duration and severity of patient-reported dysphagia outcomes at up to 24 weeks postoperatively. In particular, the inclusion of C3-C4 and C4-C5 into the fusion may be associated with dysphagia severity.

The Impact of Socioeconomic Status on the Presence of Advance Care Planning Documents in Patients With Acute Cervical Spinal Cord Injury.

INTRODUCTION: Patients presenting with spinal cord injury (SCI) often times have notable deficits or polytrauma and may require urgent decision making for early management. However, their presentation may affect decision-making ability. Although advance care planning (ACP) may help guide spine surgeons as to patient preferences, the rate at which they are available and disparities in ACP completion are still not understood. The objective of this study was to evaluate disparities in the completion of ACP among patients with acute SCI. METHODS: All patients presenting with cervical SCI to the emergency department at an urban, tertiary level I trauma center from 2010 to 2021 were identified from a prospective database of all consults evaluated by the spine service. Each patient's medical record was reviewed to assess for the presence of ACP documents such as living will, power of attorney, or advance directive. Community-level socioeconomic status was assessed using the Distressed Communities Index. Bivariable and multivariable analyses were performed. RESULTS: We identified 424 patients: 104 (24.5%) of whom had ACP. Patients with ACP were older (64.8 versus 56.5 years, P = 0.001), more likely White (78.8% versus 71.9%, P = 0.057), and present with ASIA Impairment Scale grade A SCI (21.2% versus 12.8%, P = 0.054), although the latter two did not reach statistical significance. On multivariable logistic regression, patients residing in at-risk communities were significantly less likely to have ACP documents compared with those in prosperous communities (odds ratio [OR]: 0.29, P = 0.03). Although patients living in distressed communities were less likely to complete ACP compared with those in prosperous communities (OR 0.50, P = 0.066), this did not meet statistical significance. Female patients were also less likely to have ACP (OR: 0.43, P = 0.005). CONCLUSION: Female patients and those from at-risk communities are markedly less likely to complete ACP. Attention to possible disparities during admission and ACP discussions may help ensure that patients of all backgrounds have treatment goals documented.

Evidence and Controversies in Geriatric Odontoid Fracture Management.

Geriatric odontoid fractures are some of the most common spine injuries in our aging population, and their prevalence is only continuing to increase. Despite several investigational studies, treatment remains controversial and there is limited conclusive evidence regarding the management of odontoid fractures. These injuries typically occur in medically complex and frail geriatric patients with poor bone quality, making their treatment particularly challenging. In this article, we review the evidence for conservative management as well as surgical intervention and discuss various treatment strategies. Given the high morbidity and mortality associated with odontoid fractures in the elderly, thoughtful consideration and an emphasis on patient-centered goals of treatment are critical to maximize function in this vulnerable population.

Patients Who Have a Prior History of Pulmonary Embolism Require Increased Postoperative Care Following Total Joint Arthroplasty.

BACKGROUND: This study examined the effect of prior pulmonary embolism (PE) on total joint arthroplasty (TJA) outcomes. METHODS: We reviewed patients who had a prior PE undergoing TJA at a single tertiary medical center between January 1, 2012 and January 1, 2021. There were 177 TJA patients who had a prior PE who underwent 1:3 propensity-matching to patients without a history of prior PE. Bivariable and multivariable analyses were performed. Changes over time were evaluated. RESULTS: Patients undergoing total knee arthroplasty who had a prior PE had more complications (25.3% versus 2.0%, P < .001), and postoperative PE (17.3% versus 0.0%, P < .001).and longer hospitalizations (3.15 versus 2.32 days, P = .006). Patients undergoing total hip arthroplasty who had a prior PE demonstrated more complications (14.7% versus 1.77%, P < .001) more postoperative PE (17.3% versus 0.0%, P < .001), and longer hospitalizations (3.30 versus 2.11 days, P < .001). Over the study, complication rates and hospitalizations lengths remained elevated in patients who had a prior PE. On multivariate analyses, prior PE was associated with longer hospitalizations (ß: 0.67, P = .015) and increased complications (odds ratio [OR]: 9.44, P < .001) among total hip arthroplasty patients. Total knee arthroplasty patients had increased readmission (OR: 4.89, P = .003) and complication rates (OR: 21.4, P < .001). CONCLUSIONS: Patients undergoing TJA who had a prior PE are at higher risk of requiring postoperative care. Therefore, thorough preoperative evaluation must be implemented, especially in clinical environments lacking resources for acute care escalation.

Subfascial Lumbar Spine Drain Output Does Not Affect Outcomes After Incidental Durotomies in Elective Spine Surgery.

OBJECTIVE: Postoperative drains have long been regarded as a preventive measure to mitigate the risks of complications such as neurological impairment by reducing fluid accumulation following spine surgery. Our study aims to contribute to the existing body of knowledge by examining the effects of postoperative drain output on the 90-day postoperative outcomes for patients who experienced an incidental durotomy after lumbar decompression procedures, with or without fusion. METHODS: All patients aged ≥18 years with an incidental durotomy from spinal decompression with or without fusion surgery between 2017 and 2021 were retrospectively identified. The patient demographics, surgical characteristics, method of dural tear repair (DuraSeal, suture, and/or DuraGen), surgical outcomes, and drain data were collected via medical record review. Patients were grouped by readmission status and final 8-hour drain output. Those with a final 8-hour drain output of ≥40 mL were included in the high drain output (HDO) group and those with <40 mL were in the low drain output (LDO) group. RESULTS: There were no statistically significant differences in preoperative patient demographics, surgical characteristics, method of dural tear repair, length of stay (HDO, 4.02 ± 1.90 days; vs. LDO, 4.26 ± 2.10 days; P = 0.269), hospital readmissions (HDO, 10.6%; vs. LDO, 7.96%; P = 0.744), or occurrence of reoperation during readmission (HDO, 6.06%; vs. LDO, 2.65%; P = 0.5944) between the 2 groups. CONCLUSIONS: For patients undergoing primary lumbar decompression with or without fusion and experiencing an incidental durotomy, no significant association was found between the drain output and 90-day patient outcomes. Adequate fascial closure and the absence of symptoms may be satisfactory criteria for standard patient discharge regardless of drain output.

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

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

Cellular Bone Matrix in Spine Surgery - Are They Worth the Risk: A Systematic Review.

STUDY DESIGN: Systematic Review. OBJECTIVE: To review the literature for complications and outcomes after the implantation of cellular bone matrix (CBM) during spine fusion. METHODS: The PubMed database was queried from inception to January 31, 2023 for any articles that discussed the role of and identified a specific CBM in spinal fusion procedures. Adverse events, reoperations, methods, and fusion rates were collected from all studies and reported. RESULTS: Six hundred articles were identified, of which 19 were included that reported outcomes of 7 different CBM products. Seven studies evaluated lumbar fusion, 11 evaluated cervical fusion, and 1 study reported adverse events of a single CBM product. Only 4 studies were comparative studies while others were limited to case series. Fusion rates ranged from 68% to 98.7% in the lumbar spine and 87% to 100% in the cervical spine, although criteria for radiographic fusion was variable. While 7 studies reported no adverse events, there was no strict consensus on what constituted a complication. One study reported catastrophic disseminated tuberculosis from donor contaminated CBM. The authors of 14 studies had conflicts of interest with either the manufacturer or distributor for their analyzed CBM. CONCLUSIONS: Current evidence regarding the use of cellular bone matrix as an osteobiologic during spine surgery is weak and limited to low-grade non-comparative studies subject to industry funding. While reported fusion rates are high, the risk of severe complications should not be overlooked. Further large clinical trials are required to elucidate whether the CBMs offer any benefits that outweigh the risks.

Factors Associated with Various Types of Industry Payments to Academic Spine Surgeons in the Open Payments Database.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: The objective of this study was to investigate associations between spine surgeon characteristics and different types of industry payments. SUMMARY OF BACKGROUND DATA: Industry funding has played an important role in research and technological innovation within spine surgery, and industry payments supporting research have risen significantly in comparison to funding from other sources. To our knowledge, no studies have investigated academic spine surgeon characteristics associated with different categories of industry payments. MATERIALS AND METHODS: A query was conducted of the North American Spine Society (NASS) Spine Fellowship Directory from 2021-2022 to identify all orthopaedic or neurosurgical spine fellowship selection committee members. A PubMed search was utilized to collect information on surgeon academic productivity up through December 31, 2021. We then conducted a query of the Centers for Medicare and Medicaid Services (CMS) open payments website from 2015-2021 to collect payment records of spine fellowship selection committee members. RESULTS: On linear regression analysis, total publications (8,203, P<0.001), attending years (48,823, P<0.001), and publication rate (57,528, P=0.017) were associated with higher general payments. Southeast spine surgeons (80,043, P=0.038) and fellowship directors (79,874, P=0.007) were associated with more research payments. Total publications (7,409, P<0.001), attending years (47,100, P<0.001), and publication rate (47,511, P=0.040) were significantly associated with higher royalties. Having a Twitter/X account (60,800, P=0.018), being a director (51,605, P=0.034), total publications (492, P<0.001), and publication rate (6,444, P<0.001) were all predictive of greater consulting payments. CONCLUSIONS: Spine surgeons who are experienced, academically productive, fellowship directors, and engage with social media receive greater payments on average than their peers across various payment types. As industry influence continues to make its way into healthcare, experienced leaders in their respective fields will shoulder the responsibility to integrate private innovation in an effective and scientifically rigorous manner.

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.

Does physical therapy impact clinical outcomes after lumbar decompression surgery?

Objectives: The objectives of our study were to (1) determine if physical therapy (PT) impacts patient-reported outcomes (PROMs) after lumbar decompression surgery and (2) determine if PT impacts postsurgical readmissions or reoperations after lumbar decompression surgery. Methods: Patients >18 years of age who underwent primary one- or two-level lumbar decompression at our institution were identified. Patient demographics, surgical characteristics, surgical outcomes (all-cause 90 days readmissions and 90 days surgical readmissions), and patient-reported outcomes (PROMs) were compared between the groups. Multivariate linear regression was utilized to determine the individual predictors of 90 days readmissions and PROMs at the 1-year postoperative point. Alpha was set at P < 0.05. Results: Of the 1003 patients included, 421 attended PT postoperatively. On univariate analysis, PT attendance did not significantly impact 90-day surgical reoperations (P = 0.225). Although bivariate analysis suggests that attendance of PT is associated with worse improvement in physical function (P = 0.041), increased preoperative Visual Analogue Scale leg pain (0 = 0.004), and disability (P = 0.006), as measured by the Oswestry Disability Index, our multivariate analysis, which accounts for confounding variables found there was no difference in PROM improvement and PT was not an independent predictor of 90-day all-cause readmissions (P = 0.06). Instead, Charlson Comorbidity Index (P = 0.025) and discharge to a skilled nursing facility (P = 0.013) independently predicted greater 90-day all-cause readmissions. Conclusions: Postoperative lumbar decompression PT attendance does not significantly affect clinical improvement, as measured by PROMs or surgical outcomes including all-cause 90 days readmissions and 90-day surgical readmissions.

Multilevel ossification of the posterior longitudinal ligament causing cervical myelopathy: An observational series of North American patients.

Background: Few studies regarding ossification of the posterior longitudinal ligament (OPLL) outside of Asia currently exist in the literature. A set of patients with multilevel cervical OPLL causing symptomatic myelopathy or radiculopathy from a North American sample is analyzed. Objective: The objective of this study was to describe the demographics, radiographic findings, and surgical outcomes of a cohort of North American patients with degenerative spondylosis presenting for operative management of multilevel (>3 segments) cervical OPLL. Materials and Methods: Forty-three patients diagnosed with multilevel cervical OPLL and degenerative spondylosis presenting with symptomatic cervical myelopathy or radiculopathy were surgically treated over a 9-year period at a single tertiary care academic medical center. Radiographic measurements were performed on preoperative computed tomography and magnetic resonance imaging images of the cervical spine. Clinical outcomes included pre- and postoperative Nurick scores, 90-day readmission, complication, and revision surgery rates. Results: The mean age was 66.1 ± 10.9 years with a mean latest follow-up time of 32.7 ± 16.4 months. Most patients had previous diagnoses of obesity (70.7%) and hypertension (55.8%). At least one-quarter of patients were diagnosed with type 2 diabetes (34.9%), hyperlipidemia (41.9%), cardiovascular disease (25.6%), or chronic kidney disease (25.3%). The most common OPLL subtype was segmental (39.5%) and spanned a mean of 3.54 ± 1.48 segments. Myelopathic symptoms were present in 88.4% of patients. All patients experienced significant neurologic improvement at 3-week and latest follow-up (P < 0.001 for both). Conclusions: Obesity, diabetes, and other metabolic derangements in patients with existing cervical spondylosis may be risk factors for a particularly aggressive form of multilevel OPLL. Various operative approaches may be employed to achieve adequate neurologic recovery. Further workup for OPLL in patients with these risk factors may prove beneficial to ensure appropriate operative management.

Gender disparities among speakers at major spine conferences.

PURPOSE: To examine ten-year trends in gender representation in speaking roles at major spine conferences. BACKGROUND CONTEXT: Medical conferences play an important role in career opportunities. There is little analysis on gender representation of major spine conferences despite several studies demonstrating gender disparities within spine surgery. STUDY DESIGN: Observational study. SAMPLE: A total of 20,181 abstract speakers across 10 years of academic conferences for six spine societies. OUTCOME MEASURES: Percent of female abstract presenters. MATERIALS AND METHODS: We collated the annual meeting programs of six major spine conferences (North American Spine Society (NASS), Scoliosis Research Society (SRS), International Meeting on Advanced Spine Techniques (IMAST), Global Spine Congress (GSC), American Association of Neurological Surgeons/Congress of Neurological Surgeons (AANS/CNS) Spine Summit, and the Cervical Spine Research Society (CSRS)) dating from 2013 to 2022. Departmental websites, society webpages, or personal social media were identified for images or the use of gendered pronouns in order to determine speaker gender for each speaker type. All categorical variables were compared using Pearson chi-square analysis. RESULTS: Women constituted 1,816 (9.0%) of all 20,181 identified conference speakers. Female representation was highest at NASS (N=680, 12.2%) but lowest at CSRS (6.6%) and GSC (7.1%). Spine Summit (7.4%), IMAST (9.92%), and GSC (9.87%) demonstrated the largest annual percent increases in female representation. Institutions in Middle East and Africa (1.4%), and Central and South America (1.8%) supported the lowest percent of female speakers. Women were significantly less likely to be speakers or moderators/course faculty than to be podium abstract presenters (p<.001). The percent of women as invited speakers (10.4% vs. 5.5%, p=.001) and moderators (11.4% vs. 3.7%, p<.001) increased significantly over the study period, with annual increases of 8.8% and 20.8%, respectively, from 2013 to 2022 (p<.001). CONCLUSIONS: While academic spine societies have made significant progress in promoting gender representation, especially among invited speakers and session moderators, women continue to be underrepresented compared to the percent of women in orthopedic surgery and neurosurgery.

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.

Does the Severity of Foraminal Stenosis Impact Outcomes of Lumbar Decompression Surgery?

OBJECTIVE: To establish the relationship between the magnitude of foraminal stenosis and 1) improvement in patient-reported outcomes, 2) improvement in motor function after lumbar decompression surgery, and 3) difference in surgical outcomes. METHODS: Patients who underwent one-level posterior lumbar decompression for radiculopathy were retrospectively identified. Patient demographics and surgical characteristics were collected through a query search and manual chart review of the electronic medical records. Foraminal stenosis was determined on magnetic resonance imaging and graded using Lee et al.'s validated methodology as none, mild, moderate, or severe. Surgical outcomes, motor function, and patient-reported outcome measures (PROMs) were compared based on the amount of stenosis (mild vs. moderate vs. severe). Bivariant and multivariant analyses were performed. RESULTS: Severe stenosis demonstrated more 90-day readmissions (0.00% vs. 0.00% vs. 8.57%, respectively, P = 0.019), though this effect did not remain significant on multivariate analysis (P = 0.068). There was no association between stenosis severity and the degree of functional impairment or PROMs preoperatively. Patients with moderate or severe preoperative foraminal stenosis showed improvement in all PROMs after surgery (P < 0.05) except the mental component of the Short Form 12 survey. Notably, central stenosis grade was insignificantly different between groups (P = 0.358). Multivariable logistic regression analysis did not identify any significant independent predictors of surgical outcomes or changes in PROMs. CONCLUSIONS: We demonstrated that regardless of foraminal stenosis severity preoperatively, patients have a similar improvement in PROMs, surgical outcomes, and restoration of motor function after lumbar decompression surgery for radiculopathy.

Values derived from patient reported outcomes in spine surgery: a systematic review of the minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state.

PURPOSE: While patient reported outcome measures (PROMs) define value in spine surgery, several values such as minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) help guide the interpretation of PROMs and identify thresholds of clinical significance. Significant variation exists in reported values and their calculation, so the primary objective of this study was to systematically review the spine surgery literature for metrics of clinical significance derived from PROMs. METHODS: We conducted a query of PubMed/MEDLINE and Scopus databases from inception to January 1, 2023, for studies that derived quantitative metrics (e.g., SCB, MCID, PASS) from PROMs in the setting of spine surgery with minimum 1-year follow-up. Details regarding the specific PROMs were collected including which PROM was measured, whether anchor- or distribution-based methods were utilized, the specific calculations, and the recommended value for a given PROM based on all evaluated calculations. RESULTS: Thirty-seven studies of 21,780 patients were included. The most commonly evaluated PROM-derived value was the MCID (n = 28), followed by PASS (n = 6) and SCB (n = 4). Twenty-one studies only utilized anchor-based calculations, 15 utilized both anchor-based and distribution-based methods, and one only utilized distribution-based calculations. The most commonly evaluated legacy PROMs were the Oswestry Disability Index (ODI) (N = 11, MCID range 4-20) and visual analog scale back pain (N = 5, MCID range 0.5-4.6). All 10 studies that derived SCB or PASS utilized the receiver operating characteristic methods. Among the six studies deriving a PASS value, four only evaluated ODI, identifying PASS ranging from 5 to 22. CONCLUSION: While calculated measures of clinical significance such as MCID, PASS, and SCB exist, significant heterogeneity exists in the current literature. Current shortcomings include a wide variability of reported value thresholds across the literature, and limited applicability to more heterogenous patient populations than the targeted cohorts included in published investigations. Continued investigations that apply these methods to heterogenous, large-scale populations can help increase generalizability and validity of these measures. LEVEL OF EVIDENCE: III.